Critique of US health care system

This is a powerful critique of the US health system. The vested interests are so powerful in the US it is almost certain that any reform will leave some of the most costly aspects of the system still in place. Massachussets is supposed to be a shining beacon of reform I gather but as this article shows it has many failings. Of course a single payer scheme is regarded in the US as socialist but it or some variant of it is characteristic of almost every advanced capitalist state. The US has managed to develop a costly and inefficient public system alongside an even more costly and inefficient private system. However the single payer systems are also having their own problems often resulting in two tier systems or waiting times. Off loading of costs onto individuals is now common in almost all systems.

Boston Globe - September 17, 2007

Health reform failure
By Steffie Woolhandler and David U. Himmelstein

IN 1966 - just before Medicare and Medicaid were launched - 47
million Americans were uninsured. By 1975, the United States had
reached an all time low of 21 million without coverage. Now,
according to the Census Bureau's latest figures, we're back where we
started, with 47 million uninsured in 2006 - up 2.2 million since
2005. But this time, most of the uninsured are neither poor nor

The middle class is being priced out of healthcare. Virtually all of
this year's increase was among families with incomes above $50,000;
in fact, two-thirds of the newly uncovered were in the above-$75,000
group. And full-time workers accounted for 56 percent of the
increase, with their children making up much of the rest.

The new Census numbers are particularly disheartening for anyone
hoping for a Massachusetts miracle. In the Commonwealth, 651,000
residents are uninsured, 65 percent more than the figure used by
state leaders in planning for health reform. Their numbers came from
a telephone survey done in English and Spanish. But that misses
people who lack a land-line phone - 43.9 percent of phoneless adults
are uninsured, according to other studies.

It also skips over the 523,000 non-English speakers in Massachusetts
whose native language isn't Spanish (e.g. Portuguese, Chinese, or
Haitian-Creole), another group with a high uninsurance rate. In
contrast, the Census Bureau goes door-to-door for its survey and has
translators for almost every language. It gets a more complete picture.

In sum, Massachusetts health reform planners have been wishing away a
quarter of a million uninsured people. Recent Patrick administration
claims that health reform is succeeding are based on cooked books.
According to the state's figures, almost half of the previously
uninsured gained coverage under the health reform bill by July 1. But
according to the Census Bureau, the new sign-ups amount to less than
one-quarter of the uninsured. Moreover, it's likely that much of that
gain has already been wiped out by shrinking job-based coverage - a
longstanding and nationwide trend.

Why has progress been so meager? Because most of the promised new
coverage is of the "buy it yourself" variety, with scant help offered
to the struggling middle class. According to the Census Bureau, only
28 percent of Massachusetts uninsured have incomes low enough to
qualify for free coverage. Thirty-four percent more can get partial
subsidies - but the premiums and co-payments remain a barrier for
many in this near-poor group.

And 244,000 of Massachusetts uninsured get zero assistance - just a
stiff fine if they don't buy coverage. A couple in their late 50s
faces a minimum premium of $8,638 annually, for a policy with no drug
coverage at all and a $2,000 deductible per person before insurance
even kicks in. Such skimpy yet costly coverage is, in many cases,
worse than no coverage at all. Illness will still bring crippling
medical bills - but the $8,638 annual premium will empty their bank
accounts even before the bills start arriving. Little wonder that
barely 2 percent of those required to buy such coverage have thus far
signed up.

While the middle class sinks, the health reform law has buoyed our
state's wealthiest health institutions. Hospitals like Massachusetts
General are reporting record profits and enjoying rate increases
tucked into the reform package. Blue Cross and other insurers that
lobbied hard for the law stand to gain billions from the reform,
which shrinks their contribution to the state's free care pool and
will force hundreds of thousands to purchase their defective
products. Meanwhile, new rules for the free care pool will
drastically cut funding for the hundreds of thousands who remain
uninsured, and for the safety-net hospitals and clinics that care for
them. (Disclosure - we've practiced for the past 25 years at a public
hospital that is currently undergoing massive budget cuts.)

Health reform built on private insurance isn't working and can't
work; it costs too much and delivers too little. At present,
bureaucracy consumes 31 percent of each healthcare dollar. The
Connector - the new state agency created to broker coverage under the
reform law - is adding another 4.5 percent to the already sky-high
overhead charged by private insurers. Administrative costs at Blue
Cross are nearly five times higher than Medicare's and 11 times those
in Canada's single payer system. Single payer reform could save $7.7
billion annually on paperwork and insurance profits in Massachusetts,
enough to cover all of the uninsured and to upgrade coverage for the
rest of us.

Of course, single payer reform is anathema to the health insurance
industry. But breaking their stranglehold on our health system and
our politicians is the only way for health reform to get beyond
square one.


Dr. Steffie Woolhandler and Dr. David Himmelstein co-founded
Physicians for a National Health Program and are primary care doctors
at Cambridge Hospital.


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