Physicians' Perspective: Looking to the Future of Health Care in America
by Rick Bayer, M.D.

"How do we provide universal health coverage???"

Health care delivery in the United States is a disgrace. In 1998, 18% of Americans under age 65 (44 million people) lacked health insurance. The World Health Organization ranks the U.S. health system a dismal 37th in overall performance out of 191 countries. Equally dismaying is the fact that we spend so much to get this dismal rating. The U.S. spends more per capita on health care than any other industrialized nation-$4270 per person in 1998, compared to about $2000 per person among the 29 countries of the Organization for Economic Cooperation and Development.

Because of expense, uninsured persons often can't see a physician during the early stages of an illness, and then require expensive—and preventable—hospitalization. Compared to insured adults, the uninsured receive fewer screening services to detect early cancer and heart disease, leading to an increased risk of early death.

Managed care (or more accurately, "managed cost") contains obvious conflicts of interest. The most troublesome is that health plan managers take part in decision-making that should only occur between patient and physician. Managed care creates financial incentives that penalize primary care physicians for ordering diagnostic tests and referrals to specialists. These incentives pit patients against their primary physician and primary physicians against specialist physicians. In employer-provided health insurance, the employer is likely to choose a health policy with the lowest premium to keep company overhead down, never mind the best interest of the employee.

Health care should be a right, not a privilege. We should treat health care just like education—we provide public education to all our citizens. All other industrialized nations provide universal care to citizens at a much lower cost than our system.

How do we provide universal health coverage? Recently, at an Oregon Medical Association meeting, Oregon's Governor John Kitzhaber, MD recommended expansion of Medicaid (Oregon Health Plan) to cover people at up to 200% of the federal poverty level. American Medicare and other single-payer systems used in Canada and Western Europe prove the single-payer method of financing universal health care is the most efficient and equitable solution. A publicly administered single-payer system, such as Medicare, does not have profit as its goal. Medicare consumes 3 percent of the dollar for administration whereas managed care companies utilize 10 to 30 percent of each health care dollar on marketing, paperwork, lobbying, excessive executive pay and shareholder profits. Because the single-payer method eliminates most administrative expenses, there should be money available to cover uninsured Americans.

Single-payer health care puts every citizen in the same insurance pool under a single set of rules, which will drastically cut confusing rules for physicians and for patients. Under a single-payer system, administrators are able to use purchasing power with pharmaceutical companies to lower the cost of drugs. In Canada, the cost of U.S. manufactured drugs is approximately one-third less.

Opponents sometimes dismiss single-payer universal health care as socialized medicine. But socialized medicine is a system in which the government owns the facilities and employs the health care providers. In sharp contrast, a single-payer system uses the existing private and public health care delivery system and preserves private ownership. Patients would retain choice of their physicians and hospitals.

We are convinced that most Americans, and most physicians, support health care reform based on precepts of social justice and medical need, not the current reforms driven by Wall Street. If other countries can provide universal health insurance for all citizens, surely the wealthiest nation in the world can do likewise.

Nevertheless, we must battle the greed of the pharmaceutical and insurance industries that distorted and defeated the Clinton proposal in the early 90's and just spent over $5 million to defeat a Massachusetts universal health care ballot initiative in Nov. 2000 (see www.pnhp.org). "Health Care For All" is working on a single-payer program for Oregon (www.healthcareforalloregon.org/).

The result of our efforts will be a universal health care system "by the people and for the people" that voters—banned from the corporate boardroom-can influence through local, state and federal government.

Rick Bayer, MD and Nancy Crumpacker, MD are both board certified internal medicine physicians who are married and live together in Portland, Oregon. Dr. Crumpacker specializes in medical oncology.