Editor’s note: This commentary is by Avram Patt, of Worcester, who provides consulting services in a variety of areas. He was a legislator in the Vermont House in 2015-16, retired as general manager of Washington Electric Cooperative in 2013, and previously served in the Agency of Human Services administering community-based anti-poverty programs.
[T]he president and the Republican majority in the U.S. House have pulled the plug for now on their cynical and mean-spirited attempt to dismantle our health care system. That system has its problems, some of which I’ll get to, but it serves Americans of all ages day in and day out. The way to improve it is not to dismantle it but rather, to move towards universal coverage.
A national health care system was first proposed by President Harry Truman in 1945 but that didn’t go anywhere. The Clinton administration proposed major reforms but did not succeed. Although calls for a single payer system are being proposed again, that probably won’t go anywhere in the current Congress. It’s important to keep the proposal on the table nevertheless. We do have Medicare for starters.
Most doctors opposed Medicare. I knew a doctor who didn’t.
My father, Dr. Emanuel Patt, was a family doctor who practiced from the late 1940s through the 1960s. He became a doctor because it was one way to help people and to build a better and more just world. He saw multiple generations of the same families. There was no Medicare or Medicaid and since most of his patients had no insurance, he came home from his office every day with lots of cash in small bills. (An office visit was $5 in those days.) He knew their financial circumstances and kept a sliding fee scale in his head. He counseled parents and children at a time when professional counseling was not commonly available. He went out on house calls in the Bronx. Years later, I realized that my father was an old-fashioned “country doctor,” in the city.
In 1962, President John F. Kennedy proposed “Medicare,” a national health care program for people 65 and older. The proposal was controversial, and Medicare did not become law until 1965 under President Lyndon B. Johnson. The medical establishment fought it tooth and nail, insurers, the hospitals and doctors. Those who were providing services to patients were somehow fiercely opposed to a public responsibility assuring that older Americans had health care. Dr. Patt on the other hand, actively spoke out in favor of Medicare, wrote articles, and spoke to senior citizen groups. For his efforts, he was either officially expelled or perhaps just shunned out (I’m not sure which all these years later) from his county medical society.
What I do remember clearly is a conversation he had with me back then, when I was 14 or 15. He confided to me what the best thing about Medicare actually would be. While assuring health care to everyone over 65 was a huge step, better still was his belief that it would then soon be imperative and obvious to all that everyone should have it. My father died in 1971, but if he were alive today, he would be disappointed, angry and fighting for what has since been dubbed “Medicare for All.”
About the cost of private insurance.
In 1996 as I was about to start as general manager of Washington Electric Co-op, I was handed a just-finished report recommending what to do about our skyrocketing health insurance costs. It recommended self-insurance, something being pitched to smaller employers back then. We tried it but two years later were again facing double-digit increases, so we switched to another plan administrator, only to ditch them too after a double-digit increase. We tried a high deductible plan only to see that cost quickly jump. Anyone running a business back then that provided employee benefits, or trying to build budgets for state or local government or schools can remember year after year of huge increases, some of them in the 15-20 percent range, and painful discussions about increasing employee contributions towards their benefits. At the co-op, we were forced to switch plan structures and/or plan providers five times in my 16 years there. Having since then learned a lot more about our health care systems, I know that there are good and legitimate reasons for some increases, but that there is also a lot of price manipulation and greed in the mix too. That was true then and it will continue to be true without further meaningful change.
As we get older, we usually need more health care.
The fact that this has happened in our household has allowed me, over the last 10 years or so, to see some specific examples of what is wrong and what is right with our health care services, and how we pay for them. In that short time span, life-saving, life-extending and life-improving procedures and technologies that were experimental or unknown are now commonplace. Similarly, new pharmaceuticals (such as one I know well) can have miraculous benefits. Some of these can be expensive. Those costs and the increasing numbers of people being helped by such procedures and pharmaceuticals are, in part, a legitimate driver of health care and health insurance costs.
On the other hand, that miracle pharmaceutical product I mentioned? Ten years ago, the pharmaceutical giant that developed it, and was selling it for a few thousand dollars a pop, refused to ask the FDA to approve another product, at about 1/30th of the cost, that it had developed for another purpose but which worked just as well for what I had. Private and government insurers (Medicare and Medicaid) were paying through the nose because they could not cover “off label” uses. After a lot of noise and some hearings in the U.S. Senate, that situation was rectified. We should applaud the researchers at this company, but we should recognize that corporate management was motivated by simple greed.
Coincidentally, the specialist administering that pharmaceutical during this time also had some lengthy conversations with me about how health insurers set their reimbursement rates differently for different kinds of practices performing identical procedures and services. This independent practice had twice begun to notify patients covered by one insurer and then another, that they would no longer accept their insurance. I ended up contacting high level state officials about this, as a concerned citizen. I learned through this experience that health insurance is a bit of a game, and that when patients receive an “Explanation of Benefits” statement from their insurer, they should be skeptical of a lot of the numbers they see.
The House Health Care Committee
In 2014, I was elected to the Vermont House of Representatives, served one term, and was on the Health Care Committee. The time spent in that committee room greatly deepened my knowledge and understanding of what is wrong, and what is right, with how we deliver and pay for health care, especially the “how we pay for” part. In Vermont and the rest of the nation, we have multiple payers. There are private insurers who sell policies directly or through government exchanges to individuals and to employers, or who operate plans for employers that self-insure. Some people qualify for subsidies, based on income, that help pay for private insurance. There is Medicaid, the federal/state program that is the primary insurer for low-income people and the supplemental insurer for low-income Medicare recipients. Many people whose incomes fluctuate throughout the year may find themselves qualifying for a subsidy, losing the subsidy, qualifying for Medicaid, and “churning” back and forth in an often confusing and error-prone world of eligibility requirements. It is confusing for patients, public employees, insurers, health care providers, politicians and the public.
Two years of testimony and discussion confirmed for me that how we pay is a key factor in why health care costs so much more in the United States.
There is the Veterans Administration. There are mental health services which may be paid in part by private and public insurers, as well as from other public sources. There is Medicare for those over 65. Two years of testimony and discussion confirmed for me that how we pay is a key factor in why health care costs so much more in the United States.
What I also came to deeply respect and admire was the dedication and skill of our health care professionals, researchers, nurses, EMTs, aides, technicians and all the others who serve us despite the bizarre and unhelpful systems that pay the costs.
“Don’t mess with my Medicare!”
Medicare has been around for over 50 years. It has undergone changes and adjustments along the way, as would be expected for any operation in either the public or the private sector. It will continue to face challenges in forecasting and funding as our population ages. As with any program affecting so many of us, supporting it will take commitment that rises above politics and posturing.
A few things are certain, however. Medicare is very popular with those it serves. Recipients are on the whole, satisfied with the fact that they have health care coverage, as well as with their interaction with the program. Although there are a few who disagree, studies and analysis have consistently shown that Medicare has relatively low administrative costs. In other words, Medicare is a huge government-run program that operates efficiently and effectively, covers many millions of Americans, does business with health care providers large and small, and gets high marks from those it serves. I turned 65 in 2015 and my experience matches that of most Medicare recipients.
As a legislator, hearing both from constituents, as well in discussion and debate at the Statehouse, I learned that people get very nervous whenever there is discussion in Vermont about anything they think might involve Medicare changes. This is true even though the federal Medicare program itself has begun moving away from the “fee for service” payment model that contributes to rising cost. When Medicaid and private insurers consider moving in that direction as well, some Medicare recipients, and politicians, nevertheless become alarmed that their benefits will be affected. The program runs so well and is so ingrained and accepted as a part of what our nation does, that people sometimes forget who runs it. I actually heard from one constituent in my district during the time I was on the Health Care Committee, who told me in no uncertain terms to “keep the government’s hands off my Medicare!”
Now what?
In early December 2014, the Shumlin administration announced that it was pulling the plug on “single payer.” I had not participated in the debate that led to pursuing the concept, but I followed it closely as a citizen. Although I have supported the single-payer concept, I had nevertheless been skeptical that Vermont could pull this off on its own.
I was about to start my term as a state representative, on the Health Care Committee no less. Then as now, I hoped that our nation might come to its senses and move towards a universal national system. It would take rational people in Washington working together in a bipartisan manner to get there, admittedly a long shot.
Also that month, in response to the governor’s announcement, Sen. Joe Benning, a Republican representing the Caledonia District, published a commentary entitled “Now What?” on VTDigger.org. I found myself in agreement with much of what he said, and referred to it a few times in our committee discussions. He noted some things that people on all sides of this question should keep in mind:
“To those committed to a solely free market system, let’s remember government only got involved because the free market wasn’t working. It is highly unlikely that a myriad of insurance companies will suddenly appear to provide inexpensive coverage that all can afford. To those who champion health care as a human right, let’s remember that government is not a bottomless pit of money. Any system funded by tax dollars will necessarily be limited by the extent to which revenue can be raised, meaning benefits will be limited.”
As to what we really should be working towards, Sen. Benning, while noting some limitations and likely problems, had a suggestion, excerpted here:
“In the meantime, it is also worth debating a different idea — a national solution. To even consider this idea, it would be necessary to consider universal health care as a public good, much like our national defense or interstate highway systems …
“Imagine, then, the platform known as Medicare expanded in increments over time (to minimize the impact on our economy) to eventually cover the entire population. No separate plans for congressmen or other groups; one plan for all …
“Such a system would not be connected to employment. It would not force individuals into bankruptcy or deny them coverage. It would not require school districts and municipalities to constantly chase tax dollars. It would eliminate one of the biggest bones of contention in labor disputes.”
We can and should debate exactly what this would look like and how we get there, but let’s come to our senses, rise above the present dysfunction in Washington, and actually commit to improving health care for all Americans, not taking it away. Call it “Medicare for All” or whatever you like. If he was still with us, Dr. Patt wouldn’t care what we called it, as long as we did it.
