In a NYTimes articleExpansion of Clinics Shapes Bush Legacy,
Kevin Sacks presents a real example of cost effective primary care:
As she completed a breathing treatment one recent afternoon, Willie Mai Ridley, a 68-year-old beautician, said she would have sought care for her bronchitis in a hospital emergency room were it not for the new clinic. Instead, she took a short drive, waited 15 minutes without an appointment and left without paying a dime; the clinic would bill her later for her Medicare co-payment of $18.88.
....
Ms. Ridley said she appreciated both the dignity and the affordability of her care. "This place is really very, very important to me," she said, "because you can go and feel like you’re being treated like a person and get the same medical care you would get somewhere else and have to pay $200 to $300."
At the standard Medicare co-pay rate of 20%, Ms. Ridley's office visit cost a total of $94.40. Medicare picked up $75.52 of the bill. How much, if anything, Ms. Ridley saved herself and Medicare by using the services of a community health clinic is undefined, but her satisfaction likely contains a personal financial consideration and that means that Medicare also saved dollars.
In the future Ms. Ridley may no choice but to patronize those $200 to $300 per visit providers because with state and local government funding cuts to community health centers for uninsured patients, many centers will have to close their doors. Those low income, uninsured patients will be forced to seek acute primary care coverage in the emergency rooms of hospitals. The unreimbursed cost of that care will be shifted in mysterious and complex ways to insurers and patients who are able to pay. Those lawmakers know this is crazy short-sighted thinking, but when revenues are down, taking an ax to general fund programs is so much easier and politically expedient than fixing health care and raising taxes.
(Pardon the long introduction.)
What I want to argue is that the H1N1 Swine Flu and Single-Payer have about as much to do with each other as Osama bin Laden and the Pentagon. The differences are that the :Pentagon exists and Single-Payer doesn't and to date it is assumed that bin Laden has killed more Americans than Swine Flu has. If Americans were honest with themselves they would acknowledge that the :Pentagon has killed more people than OBL could ever hope to kill. That it's an expensive, sacrosanct security blanket. Like Allstate's "good hands."
In a democracy, we may be stuck forever seeking 'mo betta government and 'mo betta political parties and politicians because there is really no more viable alternative than democracy. However, the Pentagon is no more able to deliver peace than insurance is able to deliver health. And yet, we persist in believing that they will. If only they were as innovative and creative as Wall Street in delivering safe investments with high returns. Methinks Americans are as enthralled with words like technology and entrepreneurs as many in the past were with alchemists. That fixing problems only takes a bit of magic.
There's always a tension between collective and individual good in societies/communities. The "free market," regulated markets, and public services. At one time, fire engines and fire brigades were controlled by fire insurance companies as a ;private service to their policyholders. That was competition and the free market in operation. Too often to the determinate of the collective and at a very high price to those with the financial means to buy the insurance. From our perspective today, it seems odd that it took so long for communities to recognize that public fire engines and fire brigades was a superior firefighting solution to volunteer bucket brigades and private fire companies that often got in each others way and left fires untended. (Wonder why no entrepreneurs have recently stepped forward with proposals to privatize fire departments?)
The Swine Flu scare should have reminded Americans of how much our individual health is intertwined with public health. That potable water, sanitation systems, mass vaccines, etc., all at extremely low cost, do more to prevent diseases, extend our lives, and improve our collective well-being than anything the doctors do. That public health is the most primary and critical element in any health care system. It is also the one component in the US system that is the most shortchanged or underfunded.
While collectively, the nation has breathed a huge sigh of relief that the H1N1 Swine Flu wasn't the big one and the CDC is being patted on the back for having performed well, it should be clear that our $2 trillion health care delivery system is like New Orleans levees and FEMA in 2004. Will more insurance fix that?.
US style capitalism maximizes short-term and selfish thinking. GM, Ford and Chrysler (and their union workers) not only dismissed the success of Japanese automakers but also for decades actively fought against every federal proposal for safer, cleaner and more fuel efficient vehicles. They were formidable foes to environmentalists who weren't even seeking to put them out of business by nationalizing the auto industry. With hindsight it's easy to see that they and eco-friendly consumers were locked into a lose-lose struggle unto death.
Why is Mr. Obama praising a promise from a coalition of health care providers? A two trillion dollar-ten year cost containment promise from the medical-industrial-complex if uninsured Americans are forced to buy insurance is like the promise from Wall Street Investment bankers to be good if only Glass-Steagall were repealed. This latest promise, even if sincere which it wasn't, won't be kept because the system cannot accommodate it. They're buying themselves time – interim profits -- just as Detroit did -- with little comprehension that slaying their foes is also scattering the seeds for their eventual disintegration. Another lose-lose situation.
What's interesting about the battle with US automakers is that they didn't much mind losing American consumers to foreign automakers. They even purchased parts from, adopted manufacturing methods from and invested in foreign automakers. "Hedged" their risk. Not likely because they were in league with the oil companies (a CT of the left) but because like good American corporations, they were maximizing their profits. Tiny vehicles means tiny profits and humongous vehicles reap humongous profits. It was a new day in Detroit when the SUV craze hit Americans.
Squandering our tiny political capital in demanding 'mo betta cars and buying Japanese when Detroit and DC didn't deliver was as self-defeating as the US automakers behavior. Whatever made us think that our choices were limited to making Japan or Detroit rich? Didn't that indicate that we too were as invested in the car culture as Detroit was? 'Mo betta cars are still going to save us from the certain ecological disaster of burning tens times too much fossil fuels. .
It strikes me that single-payer advocates are also invested in the US medical-industrial-complex with one modification, 'mo betta insurance. Two problems: the numbers don't work and even if they did, the levees will still fail. Problems that might be worth debating if single-payer were "on the table." As it's not, is the path to "there" (wherever that may be) limited to the current one – demanding single-payer and settling for a POS "public option?"
Consider a second real life experience of health care. One not dissimilar to Ms. Ridley's. Jessica Dur was ill, uninsured, and the community health centers had no room for her. She ended up at a Wal-Mart clinic. Saw a doctor for $59.00 cash ($34.00 cheaper than what Ms. Ridley's office visit cost) and was satisfied with the care she got.
Walmart isn’t doing anything magical. The physician isn’t spending less time, on average, with patients than physicians in for profit or non-profit clinics or private practices. The Wal-Mart physician isn’t earning less than the average community care doctor (starting salary a paltry $120,000). The doctor may even provide better patient care because she/he doesn’t have to deal with administration and patient billing and record keeping. I’m not suggesting that Walmart clinics become the provider of choice for primary health care. That $59.00 leaves out functions that we should want in our national health care and it's possible that Walmart is subsidizing part of the cost as a loss leader for its current prescription and OTC products and a potential future when it drives out the competition and can raise the $59.00 to $90.00. Plus it's patently obvious that Wal-Mart can cite their cheap clinics as evidence that their employees do have health care coverage.
Nevertheless, there is no question that Walmart clinics have eliminated the real costs of subsidizing those who can’t pay and billings. Two biggies. :Public health safety (not to mention ethics/morality), demands that we collectively provide the poor with some health care. The administrative/billing burden of the US health care system is what irks me the most. Nothing for something is dumb, but I recognize that many Americans love the nothing and the dumb. Will resist any alternative unless they don't have to change at all and can be convinced that they will save money and be safer or more secure. We can do that.
Stay tuned (only because this diary is already too long). In the interim think about Detroit, Swine Flu & Single-Payer. Two buzz words: public and free.