FORA.tv - Zeke Emanuel: Scrapping the Health Care System

FORA.tv - Zeke Emanuel: Scrapping the Health Care System (Audio only here- You may have to register.)

A lecture done for the Commonwealth Club of California on January 8, 2009.

As in his book, "Healthcare Guaranteed", he lays out his case for Health Care reform, which is for a social health insurance program. I actually agree with him, and he makes his case well. I think he gets a couple things wrong, in a way that is not helpful.

First, he spends some time being very dismissive of the single payer option. His arguments are two-fold. First, making a system work for 300 million people is impossible. Second, that continuing a fee for service system makes cost control impossible.

I happen to agree that working for a social insurance model is the best way to go, for a variety of reasons, that he covers well.

However, he is almost patronizing of those who advocate for single payer. This wouldn't be so bad if he hit the mark on his criticisms, but he does not. And it irritates and antagonizes those who would naturally on his side, if he persuaded instead of ridiculed.

Regarding managing 300 million accounts/people/policies: Our current Medicare system does not attempt to manage all of its members within a single entity. Medicare functions as the central agency, but regional carriers handle the day to day operations. And in Canada, the single payer system is broken into manageable chunks by province. There is no reason we could not implement our system in such manageable chunks.

His second argument is that fee for service is the real problem, not insurance company waste, and that we will get the most bang for our buck with payment reform rather than cracking down on insurers.

Maybe there are single payer advocates who advocate for the current reimbursement system, but I don't know any of them. So, in that sense, it is a straw man, but he really loses me when he he argues that we cannot have high performing, efficient organizations like the Cleveland Clinic or the Mayo Clinic under fee for service. I'm sorry, but those systems operate in a fee for service payment system. They have done some unique things within that system, but they are a model of how to make a fee for service system work properly. So, attacking single payer because it mandates no reform in payment models is silly and it antagonizes people who should be engaged, not belittled.

He additionally makes the case that insurance companies are not to blame for our problems and indicates that most of us would behave as these execs and employees would if placed in the same circumstances. Fine, I'll concede that, but the problem, single payer advocates point out is that the circumstances are the problem, not the employees. A system that rewards denial of care leads to massive bureaucracies designed to deny care. So, sorry, they are a big part of the problem.

And, while I'm in a critical mood, I do have a problem with suggesting VAT as a method of payment. We already have the most byzantine taxation system in the world. Why add another layer of complexity that will surely be more regressive into the mix. If you want to fund via taxes, fund via taxes. At least the income tax is somewhat progressive. And people are not completely stupid: if you tell them their taxes will go up $8000 but they won't have to pay $12,000 in health insurance premiums and another $1000 or two or three out of pocket, they'll get it.

This is intended in a spirit of constructive criticism so that we can advance the debate together.

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