A Chance to Begin From Scratch:

How Obama Can Fix The Economy and The Health Care System At The Same Time

Aaron M. Roland, M.D.

In the face of an economic crisis unprecedented in more than half a century, pundits are asking how President-elect Obama will alter his ambitious proposals.  The implication is that economic hardship must lead to scaling back or even abandonment of the change upon which he had based his campaign.  

            Certainly, in the face of changing conditions, the new President will have to reconsider his plans.  But in the case of health care, the crisis may have an unexpected effect. It may allow Obama move beyond his modest proposals to something far more comprehensive.

Obama's existing health care proposals argue for tightly regulating insurance companies, expanding employer-based health insurance, and opening the Federal employee health program to all.  But by even the most optimistic estimates this complex plan will lead to coverage of only about 50% of the uninsured and will entail a cost of up to $1 trillion over the next ten years.  In a world of $700 billion dollar bailouts, this may not sound like much, but in an economic environment where need is widespread, alternatives should be considered.

            As recently as August the President-elect voiced his support for an alternative. "If I were designing a system from scratch," he offered, "I would probably go ahead with a single-payer system."  The rationale for this idea is simple.  The private insurance based health care system has become a bureaucratic nightmare of buck-passing and profiteering.  It is rife with waste that has nothing to do with providing quality health care.  By eliminating that waste we've solved the problem.

Now, only 65% of private health insurance premiums are spent on health care. Instead, insurance company executives earn hundreds of millions of dollars while corporate marketing departments spend fortunes selling insurance to the healthy just as their utilization departments resist paying for the care of those who become ill.

On the other hand, Medicare, with centralized funding and near universal enrollment of the population it serves, provides better quality care and higher satisfaction at a substantially lower cost. Medicare's bureaucracy takes up only 3% of its funding.  No surprise, as there is nothing spent on avoiding care for the sick, marketing, or corporate profits.

The economic crisis offers the new President the opportunity most other reformers have not had--the chance to begin, as he has said, "from scratch."  The American people have voiced an overwhelming desire for change.  We have come to understand that business as usual isn't always good business and that the business models that private systems create don't always work in the public interest.  And we've learned we need to pay attention to our money.

As a doctor in the trenches of primary care, I can see no other way forward.  For my well-insured patients, a switch to Medicare for all will hardly alter the face of the health care system they currently experience.  But it will reduce everyone's level of economic and health insecurity.  None will need to worry about what is covered.  None will need to cling to unsatisfactory jobs simply to keep insured.  The process of paying for care will be simplified.

This is not socialized medicine, but a plan for public finance of our diversified private health care system. An improved Medicare for all offers relief from the waste in the bureaucratic private health care system.  It can eliminate a multitude of public and private programs which currently pay for segmented components of health care, eliminate the distinction between health care for the poor and for the rich, and reduce the confusion, waste, and annoyance which providers and patients face in dealing with the 1300 insurance companies which litter the existing health care landscape

Politics, and political change, has been described as the art of the possible.  Remarkably, the crises we face have made the seemingly impossible happen.  We have a new President, a man who has inspired our hope.  Let him begin from scratch. Let crisis and hope lead to real change.

Copyright November 5, 2008

Aaron Roland is a family physician practicing in Burlingame, California and clinical associate professor at U.C.S.F.