MODIFIED RAPTURE!

In Gilbert & Sullivan’s MIKADO, the male romantic lead, Nanki-Poo, is appalled to learn that the girl he loves, Yum-Yum, is to marry someone else.  But when she tells Nanki-Poo than she doesn’t love her fiancé,  her lover exclaims, “modified rapture!”

Just so, when I heard yesterday that Nancy Pelosi supports holding hearings on "Medicare for all," I had an all-too-brief surge of elation.  According to THE HILL, “Pelosi had said last year only that Medicare for all would ‘have to be evaluated’ and is ‘on the table,’” but now...was Pelosi actually saying that the status of Single-Payer had risen from the theoretical to the possible, which the political art might somehow make real? This was worth celebrating, EXCEPT:

•      Doug Henwood of JACOBIN magazine says that “we have this coalition now developing in Congress of Democrats opposed to any idea of single-payer,  so not obvious at this point.”
•          We have Democrats in the House who – like Joe Kennedy III – talk a good game about healthcare being a right and not a privilege – but, at the end of the day betray why they may be less than enthusiastic about it.  Kennedy, for example, says he’s concerned that – among other things – it could negatively affect investor - owned hospitals, which include Catholic hospitals in Massachusetts.  He doesn’t mention that he has taken $348,000 in campaign donations from Big Pharma, and that he owns stock in a pharmaceutical company one of whose medications – which fights Hepatitis C – costs $1000 per pill.
•         Among the ones who say they actually are for some form of “universal healthcare,” there is little agreement as to what form it should take. (See my earlier post “Various Flavors of Healthcare Reform.”)

Meanwhile everyone seems to agree that Single-Payer would save this country money. Even Koch’s Mercatus institute, in an attempt to slam the concept, estimated that in ten years it would cost this country $32 trillion -- which happens to be $2 trillion LESS than what it would cost us if we kept spending at the rate we’re spending now!  And the latest confirmation of the Single-Payer idea – from the Political Economy Research Institute (PERI) -- estimates that, when stabilized, a single-payer plan would save this country 15%-16% of GDP. 

PERI’s report -- Economic Analysis of Medicare for All – was subjected to Peer Reviews, all of which were uniformly positive:

                      Peer Review of PERI Economic Analysis of Medicare for All                    

In their review, my heroes, Woolhandler and Himmelstein, together with the redoubtable Adam Gaffney, pointed out that, based on their own researches,  PERI’s estimates of savings were less than they probably would be, while their estimates of expenses were greater than they probably would be.  In contrast to these conservative estimates,  according to Woolhandler et al,  was the optimism of Peri’s estimate of the time it would take to achieve much savings, if for no other reason than the challenge of reducing to a single computer architecture the daunting welter and variety of systems now being used.

But from my point of view, a very cogent observation was also made by Alison Galvani, who pointed out that while Medicare was pretty good at controlling prices, it wasn’t very good at controlling overuse of high-tech procedures (see my post: Why is American Healthcare So Expensive?).  She pointed out that the same McAllen doctors who, with their Medicare Patients, went through the roof in prescribing procedures that were unlikely to help, were much more conservative when it came to the Blue Cross/Blue Shield patients. He cited an article by Luisa Franzini in Health Affairs, which touted Blue Cross/Blue Shield’s supervisory measures  -- prior approval for elective procedures, and case managers for any case likely to cost $50,000 or more, and so on.  She also mentioned what I felt was one of the most important factors: "Private insurers have the advantage of a “threat point” at which they can ultimately refuse to contract for services to specific physicians or hospitals—something that Medicare cannot do."

I wondered what indeed could rein-in the entrepreneurial ambitions of Doctors.  In outfits like the Mayo Clinic or the Cleveland Clinic, Doctors are on salaries, so that nothing distracts them from focusing on the patient, who comes first.  It turns out that this way, outcomes are better while expenses are less.  Does this mean that Single-payer is going to require all Doctors to be on salaries? I wouldn’t hold your breath waiting.

But there is one economy that Galvani doesn’t mention:  As Woolhandler, Himmelstein, and Gaffney point out, that PERI analysis uses the House version’s approach to Hospitals, Clinics, Dialysis Centers:  the gradual take-over of all such privately owned facilities so that ultimately they are publicly owned,  (no stockholders) and directed NOT to make a profit.  The profit incentive being removed, these facilities are no longer incentivized to game the system and are supported globally, the way we support firehouses.  It’s a great idea, though Joe Kennedy III isn’t likely to be pleased with it.

The action in congress is thus likely to be fascinating and extremely consequential.  But that doesn’t mean we should ease up on our own efforts. Don McCanne,  a physician who writes a blog for the Physicians for a National Health Program (PNHP), writes the following:

“The hearings will be part of the process, but it is important that we continue with our other advocacy activities as well. Special targets should include politicians who do not yet seem to understand why single payer is an imperative, and politicians who profess to be advocates but who could be swayed to support detrimental reform policies in a perversion of the process of political compromise. We need to continue to work with politicians who are already fully on board, but we should also continue our efforts to educate those who say they are opposed, if,  for no other reason, they might accept defeat more readily were they to understand the clear social benefit of Medicare for All.  Also we cannot let up in the least in our efforts to educate the public at large. Grassroots efforts will continue to be an essential component of the reform effort.”  (Emphasis added)

This paragraph contains marching orders for all of us.  As the discussions intensify, both in Albany and D.C., our efforts must likewise grow stronger and more passionate.   On the day when Single-Payer passes in New York State, we all will experience not modified, but complete rapture!