Letters to the Editor
Government-Controlled Health Care Is Not the Solution
To The Editor:
In his editorial1 on health care reform published in the September
1, 2005, issue of American Family Physician,
Dr. Geyman states that health care costs can be reduced by turning our
health care delivery system over to a government monopoly. With all due respect
to Dr. Geyman, this notion ignores economic history. The 1967 House Ways and
Means Committee predicted that Medicare would cost the country $12 billion by
1990.2 The actual cost in 1990 in constant
dollars was a staggering 900 percent of that estimate: $107 billion.2
In 1987, Congress estimated the cost of the Medicaid Special Hospitals Subsidy
at $100 million in 1992.3 The actual cost was
$11 billion.3
When the Medicare Prescription Drug Benefit was
first proposed by the current Bush Administration, the price tag was originally
$400 billion. As of this writing, the most recent upward revision stands at
$1.2 trillion over the next decade.4,5
The U.S. government's track record on health care delivery cost containment is abysmal. If there is some reason that the government would suddenly become a model of fiscal responsibility and efficiency if it had monopolistic control over all health care in the country, I would like to hear it.
REFERENCES
1. Geyman JP. Family medicine and health care reform [Editorial]. Am Fam Physician 2005;72:752-5.
2. Bandow D. Principles on life support. National
Review Nov. 24, 2003. Accessed online November 29, 2005, at:
http://www.nationalreview.com/comment/bandow
200311240827.asp.
3. Edwards C. Downsizing the federal government. Policy analysis June 2, 2004;515:1-68. Accessed online November 29, 2005, at: http://www.cato.org/pubs/pas/pa515.pdf.
4. Framework to modernize and improve Medicare fact sheet [press release]. Washington, D.C.: The White House; June 6, 2003. Accessed online November 29, 2005, at: http://whitehouse.fed.us/news/releases/2003/03/20030304-1.html.
5. Connolly C, Allen M. Medicare drug benefit may cost $1.2 trillion; estimate dwarfs Bush's original price tag. Washington Post. February 9, 2005:A01.
in reply: Although Dr. Newbell is correct in pointing out the gross underestimates of future health care costs of the Medicare and Medicaid programs, it is incorrect to draw the conclusion that the government is the cause of such cost overruns. The causes of health care inflation are relentless and complex, including the impacts of medical technology, increasing age of the population, administrative bureaucracy, fragmentation of our market-based system, as well as other factors. There also is considerable evidence that the private sector alternative is less effective at controlling costs than government programs.
Using the Medicare system as an example, here are some of the reasons why we can expect that a single-payer program of government-financed national health insurance (especially if not distorted by the inefficiencies and profiteering of the private sector) would indeed be more effective in containing costs than our present market-based system:
• As a single-payer program, Medicare operates with an administrative overhead of 3 percent, whereas the overhead of private insurers is five to nine times higher1;
• Between the mid-1980s and 2000, traditional fee-for-service Medicare contained costs much better than private Medicare plans2;
• Medicare could be even more effective in cost containment if it were not hamstrung by "corporate compromises" over the years (e.g., the original political decision in 1965 to contract out administration of the program to private insurers as intermediaries for claims processing, provider reimbursement, and auditing3; the explicit prohibition in the Medicare Prescription Drug Improvement and Modernization Act of 2003 against the government negotiating price discounts of prescription drugs; and wasteful overpayments and subsidies to private Medicare plans)4;
• The Veterans
Administration, as a single-payer government program for about 5 million
veterans, is able to achieve price discounts of more than 40 percent for
prescription drugs through bulk purchasing negotiations.5 If Medicare were allowed to use its negotiating
clout for more than
41 million beneficiaries, it could obviously achieve
major savings in the cost of drugs, medical devices, and supplies; and
• Federal overpayments to private Medicare health maintenance organizations (HMOs) between 1998 and 2000 exceeded the costs of traditional Medicare by an average of 13.2 percent each year.6
The genesis of health care inflation is not the government, but rather the still unaccountable market-based system, including private exploitation of public programs as a result of political decisions along the way. Unfortunately, health care progressively is being priced beyond the reach of an ever-larger part of the population. For real health care reform, we need to seek efficient and cost-effective programs that will provide better access, affordability, and quality of care for all Americans while reducing waste and profiteering on the backs of sick people.
REFERENCES
1. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med 2003;349:768-75.
2. Boccuti C, Moon M. Comparing Medicare and private insurers: growth rates in spending over three decades. Health Aff (Millwood) 2003;22:230-7.
3. Oberlander J. The political life of medicare. Chicago: University of Chicago Press; 2003:108-12.
4. Geyman JP. Shredding the social contract: the privatization of Medicare. Monroe, ME: Common Courage Press; 2006:58-62 (in press).
5. Getting the best price: lessons learned from the Medicare discount card program. Families USA, Publication No. 05-105. September 2005. Accessed online November 7, 2005, at: http://www.familiesusa.org/assets/pdfs/Getting-the-Best-Price-Sept-2005.pdf.
6. Public Citizen Congress Watch. Medicare privatization: the case against relying on HMOs and private insurers to offer prescription drug coverage. Washington, D.C.: September 2002:9. Accessed online November 7, 2005, at: http://www.citizen.org/documents/Medicare%20report%20final.pdf.
|
Table 6 Berg Prediction Rule* |
|||||
|
Findings† |
Sinusitis |
No sinusitis |
Likelihood ratio |
Probability of sinusitis (%) |
|
|
Given 15% probability |
Given 40% probability |
||||
|
3 or 4 |
55 |
10 |
7.0 |
55 |
82 |
|
2 |
10 |
10 |
1.3 |
18 |
46 |
|
0 or 1 |
3 |
67 |
0.06 |
1 |
4 |
|
Totals |
68 |
87 |
|||
| *-Uses sinus aspiration as the reference standard. †-Presence of the following signs or symptoms: purulent rhinorrhea with unilateral predominance, local pain with unilateral predominance, bilateral purulent rhinorrhea, and presence of pus in nasal cavity. Information from Berg O, Carenfelt C. Analysis of symptoms and clinical signs in the maxillary sinus empyema. Acta Otolaryngol 1988;105:343-9. |
|||||
The article "Acute Bacterial Rhinosinusitis in Adults: Part I. Evaluation" (November 1, 2004, page 1685), contained errors in Tables 4 and 6. In Table 4 (page 1688), which discussed clinical findings and imaging studies for diagnosis of acute bacterial rhinosinusitis, the sensitivity and specificity for opacification were inadvertently transposed, and should have been listed as 41 percent sensitivity and 85 percent specificity. In Table 6 (page 1689), which discussed the Berg prediction rule, the footnotes were incorrect. The online version of this article has been corrected, and the corrected Table 6 is reprinted above.
The article "Acute Bacterial Rhinosinusitis in Adults: Part II. Treatment" (November 1, 2004, page 1697), incorrectly listed selected brand names for oxymetazoline and phenylephrine in Table 2 (page 1701). The correct brand names are oxymetazoline (Afrin) and phenylephrine (Neo-Synephrine). The online version of this article has been corrected.
Send letters to Kenny Lin, M.D., Contributing Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent (on disk) to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.
| Copyright © 2006 by the American
Academy of Family Physicians. |
