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Open Mike by Michael J. Klag
Photograph by Peter Howard

Reform 2.0

I have to find a new doctor.

Last month, my primary care physician wrote me a letter. He said he was leaving private practice. He’s an outstanding physician—a doctor’s doctor whom I’ve known since he was a medical student. His reason for closing up shop? The sheer frustration of getting paid by private insurance companies.

When a physician of his stature and skills departs private practice for a reason like that, it is an indictment of our health care system—that is, if we had a health care system. We all know the U.S. has great physicians and the world’s best medical technology. But the best health care system? Not in the least. Our crazy patchwork quilt is an accident of history and one that we need to fix. It fails us in so many ways, from its gross inefficiencies to the fact that it has left 47 million Americans without health insurance.

The evidence of our ailing health care system is pretty clear: Despite spending twice as much (more than $7,100 per capita) as the rest of the industrialized countries, we have poor health outcomes. Our life expectancy is below many other industrialized countries’ and perhaps more significantly our life expectancy has improved less than that of nearly all industrialized countries in the last 20 years. On some health status indicators the U.S. is near the top, on many near the middle and on some near the bottom. Not very good value for the extra money we spend. Where does the money go? Some of it is lost to in- efficiency. We all know you get 10 pieces of mail for every procedure or hospital visit and almost certain confusion about what you’re supposed to pay. In addition, our fee-for-service model encourages utilization of resources, especially expensive technology. Lastly, systems that emphasize primary care have lower costs and better outcomes than those that don’t, but we have created incentives that push physicians away from primary care and into increasing specialization.

Every system is perfectly designed to obtain the results it produces. Ours produces poor outcomes, inadequate access and
great inefficiency.

We have inherited a system that doesn’t work and desperately needs to be fixed.

This was the challenge that President Barack Obama vowed to address. Six months ago, his administration’s leadership on health care looked like our best chance in a generation for genuine reform. However, the political compromises that have been made thus far make it clear this historic opportunity will probably increase the number of Americans with insurance coverage but not reduce growth in costs.

To put things in perspective, let’s look back on another historic opportunity that our government did embrace. Almost half a century ago, our government committed to improving the health and economic welfare of older people in the U.S. by creating Medicare. And Medicare has been a tremendous success. Before it was instituted, 29 percent of those 65 and older lived in poverty. After Medicare, that proportion fell to about 10 percent because it provided health insurance coverage to all Americans over age 65. Since then, the health status of older people has improved markedly. Even its critics admit that Medicare’s administrative costs are a fraction of those of private insurers.

Medicare is not perfect, of course. Despite its warts, however, Medicare has been a success and a huge benefit to our older population. Now, we need to take that kind of step for the rest of Americans.

As I write this, I am not sure what the outcome of health care reform efforts will be. The sausage will go through the grinder, and we’ll get, in my view, a suboptimal solution. Far from  wallowing in disappointment, however, I’m moving on and so should our country. President Obama’s reforms can serve as the foundation  for the more comprehensive fix that’s needed. Call it Reform 2.0.

If we want true health care reform, we need a single-payer system. In this system, the government would act as administrator, paying for all patient visits, prescription drugs, medical procedures, and so on. Instead of thousands of different insurance companies, HMOs and others with all of their separate forms and billing contacts, doctors, hospitals and others would deal with a single administrator—eliminating waste in our system. At a large hospital, this would dramatically reduce overhead costs, allowing hundreds of people to be retrained so that their talents could be directed to ways that would have greater societal benefit than paper shuffling.

Those of you shaking your heads and saying it can’t be done should know that it has been done—repeatedly. Korea in the 1980s and Taiwan in the 1990s, for example, revamped their health care systems. They have multiple insurers but all follow the same rules. Korea’s and Taiwan’s leadership (including many of our alumni) scrutinized health care programs around the world and chose a system that works best. It is not socialized medicine. The hospitals and providers do not work for the government, they work for private organizations. They just don’t have to deal with the time-sapping, unnecessary administrative burdens of our inefficient system.

Every system is perfectly designed to obtain the results it produces. Ours produces poor outcomes, inadequate access and great inefficiency. It places tremendous burden on both providers and payers and drives great doctors like mine to other careers. As hard as it is, we must completely reform our system. Otherwise we risk bequeathing to the next generation the same problems we struggle with today.


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  • Richard R. Curtin, M.D.

    Ft.Myers, FL 12/03/2009 04:11:17 PM

    As a retired general surgeon I feel strongly that we have a moral obligation to supply health care to all, and single payer is the only way to go.

  • kenny jones

    portland, or 12/03/2009 04:42:55 PM

    Thank you for stepping up to the plate and stating the obvious, simple truth.

  • Jackson Day

    Columbia, MD 12/03/2009 04:56:50 PM

    Good to read this.

  • Dr. Christine Adams

    Houston, TX 12/03/2009 05:57:01 PM

    Single payer is the rare combination of the best moral solution also being the best economic solution.

  • Walter Tsou, MD, MPH

    Philadelphia, PA 12/04/2009 04:36:16 PM

    It is gratifying to have the Dean of Hopkins School of Public Health state it clearly: We need a single payer plan in this country. It would revolutionize health care, and it would make public health even more important than it is now. Bravo Dean Klag!

  • jack kashinsky

    jackann410@aol.com 12/04/2009 11:13:28 PM

    as a health organizer/planner, I would agree that single payer is the most humane and cost effective way to go.

  • Ann Coleman

    Homewood Campus, Baltimore, MD 12/07/2009 12:37:16 PM

    Thank you, Dean Klag, for putting forth a clear message on this issue.

  • James L. McGee

    Bethesda, MD 12/07/2009 06:22:00 PM

    Thanks for speaking out. Believe me it is just as frustrating on the plan sponsor side.

  • Bogdan Juncu-Lungulescu

    Cluj-Napoca, Romania 01/16/2010 12:41:29 PM

    Sir As we fully empathize with your condition, we are compelled to share the following: - A respected rural community medical doctor in Oriental Carpathians in Northern Romania, 21 years now in his apostle role, recently observed, during a cigarette smoke-surrounded interview, that (1) never in his practice had he had to bear such neglect on the part of public authorities as the one he now experiences, (2) yet if he were to be given the chance to start anew, he would do everything the same way. - 18 km. from the center of Cluj-Napoca, an economically booming city with century-old traditions in medical research, teaching and practice, villages do not have regular medical services and are partially deprived of safe drinking water. - It is painful to bear the sight of under-financed, physically decayed rural medical centers in partially deserted villages across Romania, or to hear, from the very doctor mentioned above, that the running joke in his neighborhood is “the best doctor in X (name of the main city 12 km. from his village, city which also serves as a holiday resort for the nouveaux riches) is the night train to Y (name of a much larger and better endowed urban center in Northern Transylvania, 200 km. from X)”. Cynicism? We at the Center for Health Policy and Public Health in Cluj-Napoca (which happens to be the above mentioned Y) think not. Why, when in the wake of the chaotic transition out of the similarly disjointed Communist regime, we have all the reasons to complain and play the cry baby of the European Union? First, there are already plenty of cry babies in the EU and we have our vanity. Second, because the “production-possibility frontier” of the public health sector is well behind its optimum level: there is a human resource potential largely untapped due to poor organization of medical and social work institutions; technological endowments are undergoing surprisingly rapid transformations, including through leaping from inexistent or obsolete copper telephone lines to optical fiber high-speed connections in even the most remote of mountainous rural areas; and, perhaps least visibly, the revolution in expectations regarding the quality of public social services. So, funnily enough, the 2 million Romanians that left the country in the last years since EU accession are not only fuelling economic growth through their multi-billion remittances, but are also bringing about, together with the publics’ exposure to Western-driven mass-media, a qualitative shift on the demand side of the public health system. Recent elections showed how much public perceptions of political performance and demands from elected officials changed from the unanimous voting that had been occurring during Communist times only 20 years ago. So, collegially and hopefully constructively, we warmly encourage you to keep the flag up and the good work going. We have a lot to learn from you. Cordially yours, Catalin Baba, Dean, MVD, PhD, Faculty of Political, Administrative and Communication Sciences, University Babes-Bolyai, Cluj-Napoca, Romania (www.polito.ubbcluj.ro) Razvan M. Chereches, MD, PhD, Executive Director of the School of Public Health, University Babes-Bolyai, Cluj-Napoca, Romania (www.publichealth.ro) Bogdan M. Juncu-Lungulescu, MA, PhD candidate, Researcher, Center for Health Policy and Public Health, University Babes-Bolyai, Cluj-Napoca, Romania

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