By: Johnathon S. Ross MD,MPH

Johnathon S. Ross MD,MPH — Wed, 28 Dec 2022 00:41:01 +0000

I just finished reading the NEJM on our patchwork sickness care non-system and it led me to this slog through the complex rules the ACA plans face next year to comply with next year. This article reinforced my belief that the fundamental disease of our system is its complexity. We need USA- Universal, Simple and Affordable.
In your interview with the NEJM editor, you made it sound like there was no explanation for why we ended up with a a complex patchwork. As I am sure you know, there have been universal national health insurance bills in front of Congress for 90 years including the Wagner-Murray-Dingell, McDermott-Wellstone, Conyers-Sanders, and now Jayapal-Sanders.
You did not point out that the AMA, AHA, and commercial insurers have vehemently opposed these bills. They also opposed Medicare and Medicaid as creeping socialism (see Ronald Reagan’s role in the AMA’s Operation Coffee Cup).
The number of administrative employees who never look a sick person in the eyes has grown 400 fold over the past 50 years since Nixon passed the HMO act. The HMO act mandated large employers offer these HMOs as a “reform”. Subsequently, policy entrepreneurs and economists have recommended dozens of other “market based reforms” to control the costs. But these costs are being driven by the ever increasing financial complexity of our sickness care non-system. The marketeers say patients need more skin in the game. They think it’s a game. We can see who is getting skinned. Market forces are the disease that is supposed to be the cure.
We have more market forces at play in the US than any other rich country. If they were working, our costs per capita would be the lowest not the highest and our outcomes would be among the best not among the worst of the other rich countries.
Currently, Wall Street is buying the health care system before we can reform it. There are fewer doctors than ever in independent practice. PCPs like me are a vanishing breed. PCPs are now unable to cope with the financial/billing complexity and are facing the complexity of pre-authorization, complex and often inadequate narrow networks of specialists, hospitals, and drugs.
Doctors will find that being a corporate employee will further alienate them from the Samaritan traditions of healthcare. Their new corporate overlords will convert them to RVU generating machines. Soon, much like nursing, doctors will unionize to protect ourselves and our patients from the ongoing profit seeking feeding frenzy and merger mania that now rules healthcare.
As a policy expert, you know all the above is true. Is more of this mess, the health care future you are advocating? You enthusiastically note that some states are trying to nibble around the edges of this mess. Why didn’t you mention the fundamental and proven reform- national health insurance based on a single payer improved expanded Medicare for all?
The CBO (December 2020) says it would save $600 B annually in administrative waste and overcharges for drugs and devices due to our unwillingness to to do the very capitalist thing negotiate! This enough savings to cover everyone including “residents” with comprehensive benefits, no copays, and no narrow networks. It would hold doctors nurses and research whole and still save $40B annually compared to the current system while being universal, simple and affordable.
CBO did a follow up study that says this reform would also improve the economy if the taxes needed to replace premiums were wisely chosen. The regressive nature of the current financing which you note during your interview would be eliminated with the rich paying more and the working and middle class paying less for better coverage and care in an actual system.
As the quality guru Deming pointed out, every system is perfectly designed to give exactly the results that it gives. The current sickness care non-system is perfectly designed to leave 30 million uninsured and 90 million at risk of bankruptcy and the highest costs and worst quality among the rich nations despite having the best doctors, nurses, hospitals, equipment and research in the world but we need a system that will deliver care to all who need it. If we want better healthcare at a better price with better outcomes and more satisfied patients and caregivers, we need improved expanded Medicare for all. Policy experts like you need to discuss this as an actual choice at every opportunity.
63% of Americans believe we need healthcare for all and the common ground is that we will all likely be patients some day. Medicare for all (Jayapal-Sanders) will save money, save lives, and it is the right thing to do.

Comments on: Proposed 2024 Payment Rule, Part 1: Insurance Market Reforms And Consumer Assistance

By: Johnathon S. Ross MD,MPH