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Column: In health care, the free-market model has failed

  • Democratic presidential candidate Sen. Bernie Sanders introduces the Medicare for All Act of 2019 on Capitol Hill on April 10, 2019, in Washington, D.C. (Olivier Douliery/Abaca Press/TNS)



For the Valley News
Saturday, June 15, 2019

“Medicare for All” is at the confluence of currents running through our nation. Consciousness is rising that we might enjoy the automatic, universal and high-quality care that is taken for granted in many nations. We trail the developed world in metrics of care like longevity, access, equity, infant and maternal mortality, and rates of death from causes otherwise amenable to care. All too often, ZIP code determines life expectancy.

The health industry sector outperforms the stock market, even as schools cannot afford insurance premiums for teachers.

Nurses and doctors watch countless people lose their health, since absent or inadequate medical coverage promotes belated attention to symptoms.

As some Americans enjoy wondrous medical advancements, others cannot afford the insulin they need. And a growing undertow of “diseases of despair,” such as suicide, alcoholism and opioid overdose, have taken their toll.

U.S. life expectancy has been declining the past three years, for the first time since 1918.

The consequences of the deregulation of medical insurance are obvious.

Costs of employee-sponsored family health insurance plans leaped ahead of inflation, from $5,791 in 1999 to $18,142 in 2016, according to the Kaiser Family Foundation. Middle-class incomes have been stagnant as wages are diverted to the “health dollar” and destined for insurance company profits and CEO salaries. Health insurance deductibles have risen 200 percent since 2008, along with other tactics that shift costs to the enrollee and discourage obtaining services.

The private managed care bureaucracy is geared to profit, and overall U.S. administrative costs are four times that of Canada and three times that of European nations, according to the Organization for Economic Cooperation and Development. Absent regulation allows unbridled and unjustified increases in drug and equipment prices. The cartel-like practice of “pay-for-delay” occurs regularly as drugmakers pay off generic companies to not produce cheaper — but otherwise identical — medication.

Apart from antitrust actions, the prices of medical products and services explode beyond what a reasonably functioning market would dictate.

It is evident that applying free-market consumer models to health care is as appropriate as applying rules of baseball to hockey.

Profits above patients

The recent effects of the corporatization of medical “providers” are also clear.

The vanishing primary care doctor runs gauntlets to get tests reimbursed and hires staff solely to interact with insurers. Burnout from the ever-expanded clerical burdens of electronic medical records thins the ranks of doctors and nurses. The promise of electronic medical records was lost when it was hijacked for capturing billings, rather than clinical utility.

(Wouldn’t it be nice if the clinician could “ask Siri” to “find last pathology report” and “schedule blood count in two weeks,” or “analyze drug interactions”?)

Companies with a duty to put stock prices above patient interests cynically exploit the professional accountability of medical staff, as physician and author Danielle Ofri observed in a recent New York Times piece, “Is Exploiting Doctors the Business Plan?”)

Abuse of the public trust is certainly not unique to health care.

Industry-aligned Cabinet billionaires dismantle the federal oversight agencies they command. “Dark money” influence is unabated and oligarchs pull the levers of national legislation. Lobbyists for Big Oil mythologize climate change, big banks set the terms of their next failures and the National Rifle Association legislates a gun dystopia. So too, Big Pharma and health insurers profit from the legislation they draft.

Urban hospitals convert health dollar surplus into real estate investments, while rural hospitals collapse in the absence of coordinated support. The Justice Department tries to dismantle the Affordable Care Act scaffolding while millions of Americans are still on it.

Our multiple, episodically introduced, parallel public insurance systems still leave 30 million Americans uninsured.

Now there are numerous proposals to achieve universal coverage, reduce complexity and cut overall costs. Some “Medicare for All” plans propose incremental dissolution of profit-directed insurance bureaucracies with a single federal payer built upon Medicare. There is no “nationalization” of hospitals or doctors, as some critics charge.

“Medicare for Some” proposals, such as the “public option,” allow non-seniors to purchase Medicare and may be more politically palatable to those with employer-coverage, but they do not reduce complexity nor lower costs, and future recessions will eliminate such coverage for many.

Other well regulated and simplified hybrid systems can be envisioned. Still, any cost-effective system, “all-payer” or otherwise, requires transparent and uniform insurance industry practices, enforcement of existing regulations and the enabling of negotiation between tax-supported payers and drugmakers. So expect smoke, mirrors and twitters of fear, uncertainty and disinformation from the Partnership for America’s Health Care Future — a coalition of lobbying groups including America’s Health Insurance Plans, the American Medical Association, the Federation of American Hospitals and BigPharma — which is already hard at work.

We realize that the anonymous “dark money” financing of election efforts and the sanctioned bribing of Congress is incompatible with a representative democracy. Citizen efforts to create legislation for policies that have long had overwhelming support have been stymied by misinformation and the stoking of division, whether it be by the AMA or the NRA.

Still, the tide may be turning. Young people and an energized electorate are clamoring to “promote the general welfare, and secure the blessings of liberty” offered in the preamble to the Constitution. We will recognize such a democracy when, among other changes, this wealthy nation fulfills the moral imperative of assuring modern, universal and affordable health care to all Americans.

Kenneth Dolkart is a physician who lives in Grantham