THE SINGLE PAYER CONCEPT #2: Undoing the Skewed Rhetoric

First, although the placement of a single payer for American healthcare service and product under the sponsorship of the federal government, which seems to be a natural course of events, might seem to fulfill the economic-political policy definition of socialized medicine (that the government owns and operates both the financing of health care and its delivery, http://economix.blogs.nytimes.com/2009/05/08/what-is-socialized-medicine-a-taxonomy-of-health-care-systems/), I don’t think it does because I don’t see a change in ownership of anything but rather, just a change in which organization administers payment of the bill. Nor does it follow that this change must fulfill the effective meaning of socialized medicine, which is to control the functioning of the doctorpatient relationship in an effort to control health care expenditure, i.e., to control the practice of medicine to reduce cost. Fulfilling the effective meaning of socialized medicine, which the current British, Canadian, and American systems so capably do, adds a major conflict of interest on top of the mutual trust, which is the doctorpatient relationship and from which sound, ongoing, non-conflicted health care is supposed to ensue. And this dollar based conflict of interest is every bit as damaging as a doctor, who performs procedure after procedure or test after test just for self-enrichment.

So, does a single payer system have to fulfill this effective meaning and fear of socialized medicine? The answer is, Of Course Not, IF IT IS STRUCTURED PROPERLY.

Well then, how can we create a single payer system under the sponsorship of the federal government without subjecting it to the cunning, scheming, unscrupulous, and disastrous manipulations, which our Washington, DC politicians, the federal government, have unleashed upon our healthcare system for the last many years up to and including the ideological farce, the Affordable Care Act, (ACA)?

I believe the answer is to create a separate, independent paymaster similar in structure to the Ken Feinberg–BP Oil Spill Escrow Fund Payout System, which administers claims payments related to that event. Independent is a key feature. The paymaster of my single payer system would not be beholden to the government nor to any healthcare business or corporation, including hospitals, health insurance carriers, and drug companies. The paymaster and his/her team of healthcare-business-experienced negotiators would have the same authority and isolation as the Supreme Court of the USA. In other words, their decisions regarding payment for services and product would be final and only changed by themselves or their future members. Notably, they would have NO INFLUENCE over how medicine is practiced, i.e., no influence over the functioning of the doctorpatient relationship. Cost control would be accomplished by straightforward, transparent NEGOTIATION between the individual healthcare business, including individual hospitals, and healthcare-business-career-experienced members of the paymaster’s team. These negotiations would not be punitive in attitude nor with an attitude that good, decent profit is a bad thing. Quite the contrary, they would have to be conducted with an attitude that good profit over and above clear assessment of absolutely necessary overhead is vital for our wonderful healthcare businesses and corporations. The definition of absolutely necessary is a major part of the negotiating process. Also note that the paymaster’s negotiating teams would consist of experienced healthcare business people, who worked many years in the domain of the companies, hospitals, or corporations with which they are negotiating the prices to be paid by the single payer for their services and product.

My effort in this discussion is to try to describe an administrative mechanism, which frees up the doctorpatient relationship to do what it is supposed to do, while also ascertaining agreed-upon negotiated profit margins with our healthcare businesses. Greed would be removed, national healthcare expenditure could be controlled, and the mutual trust, which is the doctorpatient relationship, could blossom. Also, it should be noted that the business practices of doctors will be part of these price negotiations, which are completely separate from the sound, ongoing, non-conflicted functioning of the doctorpatient relationship. In other words, the single payer is not negotiating with the doctor regarding how he/she practices medicine but rather only what the doctor will be paid for same. And the price a doctor, hospital, or other service is paid is the same regardless of the financial status of the patient. There will be no more bad debt and these dollar amounts will not be penurious but rather reflect the esteem, which people in general should have for the wonderful doctors and hospitals in the USA.

This can work wonderfully for our healthcare system if transparency, sound healthcare business experience, and good will are at play. This requires that the ethos of the single payer is removal of the greed within and the political power over our healthcare system. Sound, ongoing, non-conflicted functioning of the doctorpatient relationship must flourish as the primary goal, which healthcare business concerns (including doctors’ practices’ business mechanisms) must function to support, while making their own profit seeking a secondary goal, yet a goal, which is guaranteed in a good, negotiated, agreed-upon measure.

R. Garth Kirkwood, MD
doctork@equalhealthcare.org

THE SINGLE PAYER CONCEPT #1: What Is It? Can It Be Abused?

What does single payer mean, when used in the context of the American health care system? A single payer is an administrative organization, which would collect our money into a large pool and then administer payment, from that pool of our money, for our healthcare services and product. This contrasts with our current healthcare system’s administration of payment, which consists of multiple payers including the federal government, health insurance companies, and us, when we pay cash out of pocket.

Can a single payer system be abused? By abused I mean, Can a single payer system be worked to a great financial and political advantage for some (THOSE, WHO ARE IN A POSITION TO CONTROL IT) and to the great disadvantage of others (US, WHO PAY THE MONEY INTO THE LARGE POOL WITH THE EXPECTATION THAT THE PEOPLE, WHO WORK IN THE SINGLE PAYER ADMINISTRATION, FUNCTION TRANSPARENTLY, HONESTLY, AND IN OUR BEST INTEREST)? The answer is YES, IT CAN BE ABUSED. Look at the single payer systems in Britain and Canada with their long waiting lists for surgeries and specialty consultations.

However, look at our American multiple payer system. Look at the revenues of our health insurance companies, our hospitals, the vast majority of which are not-for-profit, and the money spent on lobbying politicians. Don’t waste your time looking at reported profits. A good CFO can place the profit numbers wherever the board tells him/her to place them. The revenues for all our hospitals were over 707 billion dollars in the Economic Census of 2007. The revenues for the top health insurance and managed care companies ranged from 19 billion dollars to 81 billion dollars in the Fortune 500 2009 Top Performers list. So far, it doesn’t seem like the American healthcare system abuses us with long waiting lists, save for those, who, unable to afford being part of the system yet not entitled, have a waiting period of forever. No, our American healthcare system abuses those of us, who pay taxes and/or who buy health insurance individually or via employer as part of our wages, by sucking the financial life out of us to enhance their own prosperity. I believe that most of us recognize that no service or product in America is going to be free and that companies and organizations must function with a good, annual profit after all overhead is paid. But the business empires, which have developed in our healthcare economic marketplace including our hospitals, which are independent business fiefdoms whether for-profit or not-for-profit, have changed sensible capitalism into an all out game of GREED, while placing our individual health care as a very distant secondary goal in their business plans, which fact they disguise by their false mantra of how important their social missions are to them.

Thus, in the above analysis, I do not believe that any of the mentioned healthcare systems offers a sound, ongoing, non-conflicted path, which will lead us to a plateau, where our healthcare system functions primarily in our individual healthcare interests, while placing the dollar bill as an important but definitely secondary goal.

CAN SUCH A SYSTEM BE DEVELOPED IN AMERICA? OF COURSE IT CAN. WHY NOT? WHAT’S STOPPING US?

I will discuss this ideal system in the next few posts on this blog.

R. Garth Kirkwood, MD
doctork@equalhealthcare.org

Socialized Medicine, Its Pejorative Connotation and Effective Meaning: American Health Care Is Already Socialized

What is the fear that people feel, when they hear the words, “Socialized Medicine?” I believe it’s the fear that a government will interfere with the practice of medicine in their country and somehow restrict or ration the medical care, which they can receive. I also believe that this fear is well founded, since that is precisely what occurs in the British National Health Service (NHS) and in the Canadian System. Long waiting lists for surgeries and specialty consultations are the prototypic example of this interference.

Well, just what is the practice of medicine? The practice of medicine, the essence of medicine, is the doctorpatient relationship, from which non-conflicted medical decision making is supposed to ensue. And this is the exact place, where those governments interfere.

What is socialized medicine, really? Socialized Medicine refers to a health system in which the government owns and operates both the financing of health care and its delivery. (http://economix.blogs.nytimes.com/2009/05/08/what-is-socialized-medicine-a-taxonomy-of-health-care-systems/) I refer to this as an economics-political policy definition, and it does not apply to the American healthcare system, outside of the V.A. health system, which is a pure form of socialized medicine (Ibid: above link).

However, what is the effective definition of socialized medicine, the on-the-ground, actual definition? Of course, it must mean socialized doctorpatient relationships, i.e., relationships between doctor and patient, which are influenced, affected, controlled, or obstructed by powers and forces, from the government payer or any other payer, extraneous to the simple, mutual trust between the two participants.

Now, let’s take another look at the American healthcare system. Outside of our government payer for our various entitlement programs, does any other payer try to influence the functioning of the doctorpatient relationship? The answer is an emphatic Yes. Health insurance carriers, managed care companies, and HMOs try to control the functioning of the doctorpatient relationship by forcing various plans and restrictions upon it, ranging from outright obstruction to financial incentives for doctors and patients.

Why do they do this? Because the doctorpatient relationship is the proximal source and cause of healthcare spending in the USA, and their motive is to reduce that spending as much as possible, so that they can keep more money for themselves and their other business agendas outside the practice of medicine.

Thus, American Health Care is already “Socialized” and has been for a long time. However this fact is hidden from the general public (hidden in plain sight) by the continual use of the obfuscating rhetoric, which compares the Private vs. Public payers. As long as the politicians, health insurance carriers, hospital administrators, and other healthcare corporate leaders keep this rhetoric in play, the average person will continue to fear a single payer system. And, that’s their goal: Keep the average person bewildered so that their intertwined web of greed and power can continue, unrecognized for what it is. This web exists for politicians of both major parties, and, I expect, it will also entrap the Tea Party politicians.

The reason to keep this fear spreading among the American people is that a single payer could effectively ‘Unsocialize’ the doctorpatient relationship, i.e., allow it to develop and function free of restrictions imposed by the payer, and ‘Socialize’, bring some order and control to, the unbridled, greed-driven capitalism of our healthcare economic marketplace. This would be the exact opposite of our current system, which privatizes the business of medicine and socializes the medicine of medicine. All of us actively supporting this opposite effort is the path for true healthcare reform. My book, Socialized Health Care Reform ISBN: 978-0-9829947-0-2 clearly explains all of this and describes a way forward, which would benefit everyone living in America, save greed-driven healthcare business people and power-driven, arrogant politicians.

In my next post, I will try to explain how I see this single payer functioning, so that it does not fall prey to the cunning, scheming, unscrupulous, and disastrous manipulations of the healthcare economic marketplace, which is networked with Washington, DC.

R. Garth Kirkwood, MD
doctork@equalhealthcare.org

The Affordable Care Act’s (ACA) Challenge for States: Securing Primary Care Services

The New England Journal of Medicine (http://www.nejm.org/doi/full/10.1056/NEJMp1011623) contains the article, The State’s Next Challenge– Securing Primary Care for Expanded Medicaid Populations, by L. Ku, Ph.D., M.P.H. and others from the Department of Health Policy, George Washington University, Washington,DC. Although the statistical data in the article and analysis of same may well be correct, it doesn’t offer any practical solutions, and the meaning of its rhetoric remains disguised.

(The sentences in italics are from the article; the non-italicized parts are my commentary.)

(Page 1. of article) However, since many of the states with the largest anticipated Medicaid expansions are also the ones that have less primary care capacity, they could face surging demand from the newly insured without having sufficient primary care resources available. These gaps could affect access to care not only for the newly eligible Medicaid beneficiaries but also for others who depend on a state’s existing supply of clinicians.
One solution for this could be to ask the specialists in the state such as cardiologists; lung and kidney specialists; gastroenterologists; endocrinologists; etc. to provide primary care services as well as specialty services for the patients in their region. To receive certification from the American Board of Internal Medicine (ABIM) in one of these specialities requires that the physician must be previously certified in internal medicine by the ABIM (http://www.abim.org/certification/policies/imss/pulm.aspx). Physicians in internal medicine are considered to be primary care providers. The specialists are trained internists to begin with and are certainly capable of providing the primary care services that internists provide. If this happened, it could effectively delete one layer of back and forth referral (substantial cost savings) and the patient could receive both levels of service, primary care and specialty care from the same doctor, who by definition has advanced knowledge. I wonder if this would help doctors to see patients as whole human beings instead of as the man with kidney failure, the woman with anemia, etc.
Some other thoughts regarding this potential dual role for specialists:
1. Increased Medicaid fees for primary care services to 100% of Medicare rates in 2013 and 2014 is not adequate. It should be permanent.
2. The payment of these fees should be electronically immediate without the ridiculous paperwork required from doctors’ offices, which greatly increases their overhead.
3. The increased Medicaid fees should not be restricted to primary care services but extend to specialty services as well.
4. Of course, one must realize that if something like this happened, i.e., patients actually being seen for their illnesses by a doctor with advanced knowledge, this could effectively end the Gatekeeper Concept, which would disrupt one of the underlying cost-control plans of the ACA and of the health care reform experts of both the private and government payers: Herd people into primary care holding pens like cattle and restrict their access to specialists.

(Page 3. of article) Many of the highly challenged states have a lower-than-average ratio of advanced practice clinicians to primary care physicians, so are less able to utilize efficient team-based care.
Well, if a specialist was delivering primary care services and specialty care services, the entire doctor part of the team could be wrapped up in one person, unless other specialists’ knowledge were required. I have written previously about how medical school and post-graduate training programs could be arranged to provide this degree of training as opposed to ending post graduate training at the primary care level (Chapter 6 of Equal Health Care For All (copyright 2007) http://www.amazon.com/Equal-Healthcare-M-D-Garth-Kirkwood/dp/0979699401/ref=sr_1_33?s=books&i.e.=UTF8&qid=1308674050&sr=1-33

(Page 3. of article) Many (states) also have limiting scope-of-practice laws that restrict nonphysician clinicians in places where their skills are most needed, as the Institute of Medicine has recently noted.
My view is that ‘nonphysician clinicians’ is a paradox in terms. True clinicians have gone to medical school, received an MD degree, and participated successfully in post-graduate training programs of several years duration, resulting in certification in one or more specialities. The nonphysicians, who see patients, do not, in my view, deserve the title of clinician and should be employed by and supervised by the same physician, who accepts ultimate responsibility for the quality of their work.

(Page 3. of article) The ACA takes a fundamental first step toward improving access to care by expanding insurance coverage.
I presume this statement includes the expanded Medicaid population as ‘covered by insurance’. The reason for making this presumption is that expanding the Medicaid population will allow insurance companies to raise their premiums and deductibles and pursue other dollar-garnering mechanisms, which significantly and adversely affects those people, who actually do purchase health insurance, either individually or through their employers as part of their wage. Ideological cover for this greed is provided by the cost-shift argument. I discuss the cost-shift, the concepts of the business of medicine vs. the medicine of medicine, and how the American healthcare system already is, effectively, socialized in my new book, Socialized Health Care Reform, copyright 2010. http://www.amazon.com/Socialized-Health-Care-Reform-ebook/dp/B004QTOF4S/ref=sr_1_1?s=books&ie=UTF8&qid=1341679760&sr=1-1&keywords=Socialized+Health+Care+Reform+by+R.+Garth+Kirkwood%2C+MD

Another antagonistic, in my view, accomplishment of the ACA is that it leaves in place a main aggravating factor for ongoing discrimination in our healthcare system: The concepts of entitlement population, indigent, and poor in our medical lexicon, while expecting the people in the USA, who actually pay taxes, to pay for it with those taxes. If the ACA is so laudable, why didn’t it offer a ‘public option’ for everyone, in which everyone could participate and which would use the power of volume leverage to control the exorbitant prices paid to hospitals (FP and NFP), pharmaceutical and technology companies, and other healthcare businesses. Surely this also could have been the death knell for health insurance carriers, which cause so much misery. The public option could bring control to, ‘socialize’ the business of medicine.

There seems to be real worry in this article over whether we will have enough primary care physicians to handle the changes the ACA brings upon us. Is that the worry or is it worry over the final curtain for the Gatekeeper Concept because there won’t be enough primary care physicians to keep everyone in primary care holding pens and restrict their access to specialists. Gosh! Then the payers, both government and private, would hit a major obstacle in their ongoing efforts to ‘socialize’, control the function of, doctor patient relationships, the medicine of medicine, by restricting which type of doctors patients can see.

Could this be the start of true healthcare reform: A Public option coupled with not enough primary care physicians causing the opposite effects of our current system, which so gloriously privatizes the business of medicine and so surreptitously tries to socialize the medicine of medicine, the doctorpatient relationship, no matter which payer is up to bat?

Now the question I have for the authors of this article and for the editorial board of the New England Journal of Medicine is this: Are you part of the ongoing rhetoric and spin, which disguises the real meaning and effect of the ideological farce called the Affordable Care Act, or are you just, as General Honore says, “STUCK ON STUPID?”

R. Garth Kirkwood, MD
doctork@equalhealthcare.org
www.equalhealthcare.org

Michele Bachmann and the Crown Jewel of Socialism: Obamacare Equals Socialized Medicine

Although I can understand how one could equate Obamacare with socialized medicine, I don’t think it fulfills the definition of same because it leaves in place the insurance companies as well as out of pocket spending, in addition to any government payer. Thus, there is not the exclusive use of public funds to pay for our healthcare system; the government does not own and operate both the financing of health care and its delivery (http://economix.blogs.nytimes.com/2009/05/08/what-is-socialized-medicine-a taxonomy-of-health-care-systems/). Nevertheless, Obamacare needs to be repealed because: First, it is a gift to the insurance companies, which will allow them through their convoluted business rhetoric to significantly and regularly increase insurance premiums and deductibles; Second, it is a ploy to increase a large democratic voting block, the Medicaid Entitlement population; Third, it did not create a public option, which is the way, if handled in a proper, clean, and transparent fashion, to create true competiton for the health insurance companies and rid ourselves of the misery, which they cause.
Congresswoman Bachmann does not understand the economic-policy definition of what socialized medicine is, nor does she understand the true, effective meaning of socialized medicine, which is control of the practice of medicine by the payer, whether that payer is private or public. If she widened her scope some, maybe she would ultimately arrive at an understanding of what true, beneficial healthcare reform would entail.

R. Garth Kirkwood, MD
doctork@equalhealthcare.org

Me and the Canadian System

It has been suggested that I prefer the Canadian-type healthcare system over our own American system. From an economic-business-political-ideological policy perspective, I can understand how one might reach that conclusion. However, although the different analyses and conclusions which fall within its domain are what currently guide the creation of legislation pertaining to our American healthcare system, this perspective needs to be replaced (as our guide) because not only is it not based on the medicine of medicine, the doctor patient relationship, it actually thwarts development of same and makes this fundamental essence of health care the servant of economic-business-political-ideological policy.

Thus, I am directly opposed to the Canadian system, which keeps costs in check in part by controlling the supply of certain services– for example, imaging and surgical facilities and the specialist physicians necessary to carry out the procedures. The result is the growth of waiting lists for some procedures. (“Privatizing health care is not the answer: lessons from the United States” by Marcia Angell MD CMAJ October 21, 2008 179(9) (http://www.cmaj.ca/cgi/reprint/179/9/916) Thus, the payer is, in effect, practicing medicine instead of simply administering payment of the bill for medical decision making, which occurs within the doctor patient relationship. I do not believe that people living in any country send their money to public payers (government’s taxes) or to private payers (health insurance companies’ premiums) with the expectations that these business administrations will be making medical decisions, which is, in effect, what a waiting list is.

Influencing the functioning of doctor patient relationships to control costs is just as conflicted as any doctor who performs procedure after procedure just for the money.

As well, I am not in favor of physician entrepreneurship or entrepreneurship in general in the American healthcare system. There is a brief, instructive discussion about the dollar quest of US healthcare businesses in the article referenced above. What needs to change in the American system, for sound healthcare reform, is its underlying ethos, its aspirations. The dollar quest should be replaced by the quest, a demand, for the medicine of medicine, the doctor patient relationship, to be open to everyone in an affordable manner, which makes the dollar bill the servant, the fundamental support, of this demand as opposed to the opposite, which is the current state of affairs.

This sounds idealistic, naive and corny, and it is exactly what we need from our politicians and their economic advisors. So far, those plans and ideas for change that have been offered to and/or hoisted upon us by politicians of every party designation; their advisors from different spheres; think tanks, which support one agenda or another; lobbyists, who disguise themselves with different designations; and others are nothing more than convoluted tweakings of our already dysfunctional system. These people, who function in the veiled reality of this realm, which obstructs real, beneficial change, will never be able to recreate the wheel because they are so dependent on it. We need to change current reality, i.e., recreate the wheel of American healthcare policy, so that it is guided by the medicine of medicine not the business of medicine.

I do not favor the Canadian system, the British system, or the American system. I favor a complete overhaul, the fundamentals of which I have described in my books: Equal Health Care For All (2007) and Socialized Health Care Reform (2010)

R. Garth Kirkwood, MD

Best Healthcare Plan

Professor Laurence Kotlikoff’s recent article on Bloomberg news, “Health Law’s Demise May Permit Best Plan,” yields several points regarding healthcare reform, which I want to critique. ( http://www.bloomberg.com/news/2010-12-29/health-law-s-demise-may-permit-best-plan-commentary-by-laurence-kotlikoff.html ) In this discussion, italicized sections come directly from this article and are followed by my own discussion.

It’s a sad legal system that confuses linguistics for principle. But adherence to original language may trump concern for original intent, even on appeal to the Supreme Court. Here, Professor Kotlikoff is discussing that different wording of the individual mandate for health insurance would have avoided the U.S. District Judge’s ruling that this is unconstitutional. Perhaps so, but I am much more interested in the words, original intent. Rather than castigate the legal system, I would suggest that the 111th Congress and President Obama used linguistics and 2000 pages of Washington DC hieroglyphics to obfuscate their intents: 1) A massive increase in their, the federal government’s, power and control over everyone’s life (via our healthcare system), at the expense of the people, who actually pay taxes and buy health insurance individually or through their employer, the latter’s benefits package being part of the employee’s wage; 2) a huge increase in the Medicaid entitlement population, which translates to a voting block, which will keep them in power.

It (Obamacare) adds another expensive entitlement–federally subsidized health exchanges, with no solid cost controls- to Uncle Sam’s continually skyrocketing Medicare and Medicaid obligations. I agree that these health insurance exchanges, which are said to be new competitive health insurance markets, a place for easier, more understandable, one-stop shopping for health insurance ( http://www.hhs.gov/ociio/initiative/index.html ), will likely not provide any solid cost control for the businesses operating within our healthcare system. I also doubt that they will make purchasing health insurance any easier for the bewildered layman.

More important, I feel, is the reference to Uncle Sam’scontinually skyrocketing Medicaid obligations. This leads us into the argument of cost-shifting, as an explanation and justification for the continually increasing health insurance premiums and deductibles, which both individuals and employers face. The cost shift is systematically higher prices (above cost) paid by one payer group to offset lower prices (below cost) paid by another ( Dobson, A. et al. The Cost-Shift Payment ‘Hydraulic’: Foundation, History, and Implications. Health Affairs, 25, no.1 (2006): 22-33 http://content.healthaffairs.org/content/25/1/22.full ). Whether you believe the cost-shift argument or not, Obamacare enables and enhances health insurance companies’ greed-driven agendas by giving them a boat load of ammunition in the form of expansion of the Medicaid population (payments lower than reported cost) and thus the cost-shift argument, which leads to progressive narrowing of what insurance companies will pay for, as well as increasing premiums and deductibles and thus more and more people unable to afford to buy health insurance. Why were the 111th Congress, completely controlled by Democrats, and President Obama, a socialist-leaning Democrat, unable to deliver the ‘public option’ as a direct way of achieving their original intent, which is presumably stated in Title 1 of the Affordable Care Act: QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS? If this was really their original intent, why were they unable to achieve it? I think they didn’t achieve it because it really wasn’t important to them. What was more important for them was to promote a massive increase in their power and control over the American people; to have those Americans, who actually pay taxes and buy health insurance (individual or via employment) pay for this expansion of power and control; and to keep themselves ensconced in Washington, DC. And they used 2000 pages of linguistics and rhetoric to accomplish these agendas.

Given the way the health-exchange subsidies and employer fines are structured, the law will likely lead to the unraveling of employer-based health care, leaving the government paying the bill of the entire population. First, getting employers out of the health benefits business could be a very good thing. Their overhead could decrease drastically, and they might be able to hire many more people. Second, the government doesn’t pay for anything. The tax paying Americans and businesses, who send money to the federal government, pay for everything. So, if there was a properly and transparently administered ‘public option’, to which everyone was required to contribute, then a fundamental fairness in our health care system could abound.

Professor Kotlikoff distinguishes our current system from ‘Socialized Medicine’. Although by standard definition this distinction is correct, the effective meaning of socialized medicine (my view) is that the payer, whether private or public, decides how medicine is practiced by deciding which illnesses and to what extent are covered and which methods of practice will be compensated and to what extent. Thus our entire system is in actuality already ‘socialized’, i.e., controlled by the payers, unless you are one of the fortunate few, who have enough money to override the progressively restrictive agendas of both private and public payers.

This understanding is crucial because Professor Kotlikoff goes on to say that everyone needs a basic health plan. This is the thinking that I fundamentally disagree with. It puts the payer in charge. The nebulousness of the word, basic, makes this concept dangerous. What everyone needs is clear and equal access to sound, ongoing, non-conflicted doctorpatient relationships, within the context of which, medical decision making occurs. The function of the payer, whether private or public, is to administer payment of the bill, not to describe health plans (basic or otherwise), which control, ‘socialize’, the functioning of these relationships. In America, we privatize the business of medicine and are trying to socialize, control, the medicine of medicine, the doctorpatient relationship. For wonderful healthcare reform, it is this concept that needs to be changed. It needs to be reversed. Control, ‘socialize’, if you prefer that word, the business of medicine and let the doctorpatient relationship alone, to develop unobstructed, while ascertaing that it functions in a sound, ongoing, non-conflicted manner. The quest for the dollar bill needs to be placed as a secondary goal in our healthcare system. Thus, I disagree with Professor Kotlikoff’s voucher system to buy a basic health plan from an insurance company because it places the insurance companies in charge of the practice of medicine. It allows them to influence the practice of medicine to suit their own agenda.

A panel of doctors determines what’s covered by the basic plan within a strict budget. Who would these doctors work for? Who would be paying their salary? Do they have a crystal ball, which would tell them what the decision making within individual doctorpatient relationships would be? This is simply socialized medicine with the central controller being the insurance companies as opposed to the government. I disagree wth it completely.

The concept in Professor Kotlikoff’s voucher system that it combines public health-care finance (all who can pay do pay through their taxes) with private health-care provision, is onerous to all those people, who do pay taxes and buy health insurance. Why should they have to pay twice to keep the insurance companies in business? And private insurers contracting with the doctors and hospitals we choose for our care, (which already happens) can compromise the functioning of the doctors and the hospitals. The insurance companies become their employers instead of the patients.

I doubt there will be wonderful healthcare reform, beneficial to everyone including healthcare businesses, until effective control is brought to the business of medicine (hospitals, insurance companies, managed care companies, doctors’ practices, other healthcare businesses) and until clear and equal access for everyone to the medicine of medicine, (the doctorpatient relationship functioning in a sound, ongoing, non-conflicted manner) is seen as the primary goal of our healthcare system.

R. Garth Kirkwood, MD