The Case for Medicare for All

For a note on today’s MLK Day holiday, click here.

For brief descriptions of and links to recent posts, click here. For an inverse-chronological list with links to all posts after January 23, 2017, click here. For a subject-matter index to posts before that date, click here.

They say that a “conservative” on law and order is a liberal who’s been mugged. But that bromide cuts both ways. A progressive—even a radical—on health insurance is a “moderate” whom our private, for-profit system has mugged.

I know, because it happened to me, quite recently. This is my story.

For ten years, I’ve been under the care of a superb physician and human being. He’s an immigrant from Egypt, a Christian who left Egypt early in his life.

This surgeon’s skill has already saved me twice, once from cancer and, later in life, from health assaults on my lifestyle. At every turn he acted as a skilled professional with a warm, caring and empathetic manner.

This doctor was and is an embodiment of the Hippocratic Oath. After I retired, I regularly sought his care at the Cleveland Clinic, traveling to see him from as far away as Berkeley, California, and Santa Fe, New Mexico.

In December I discovered that I had failed to make a recommended follow-up appointment with him. I called the Cleveland Clinic, only to find that he had left its practice. The Clinic would not tell me where he had gone or why, only that he had left.

So with no help or thanks to his former employer, I set out to track down my surgical savior on the Internet. With the aid of Google Translate, I pursued him to conferences in Arabic in the Middle East. My heart sank at the thought he might have gone too far away for me to travel. Yet after an hour of searching, I found him in another warm climate: Phoenix, Arizona. That’s just a seven-hour drive from my home in Santa Fe. So I rejoiced.

But that was when the real trouble began. My surgeon had signed on with a private organization called Valleywise Health Medical Center but had not yet begun his practice there. For two weeks, both before and after he started work, I could not contact him, his group, or any medical professional (even a nurse!) who works with him. No one could tell me when or whether I could see him for a routine diagnostic procedure.

After five or six telephone calls, one fax, and three e-mail messages, I knew no more about my surgeon’s nascent practice at Valleywise than I had from reading the brief Internet announcement of his coming. All my telephone inquiries and written messages disappeared into a black hole.

This response would have been unacceptable if I had been trying to communicate with my dry cleaner over a lost pair of pants. But my health and potentially my life were at stake.

Incensed, I demanded to speak with the “lead” of the patient “communication” team at Valleywise. She told me that my surgeon could not see patients until the business-insurance contractors who controlled the practice had “approved” him. “Was he licensed to practice medicine in Arizona?” I asked. Yes, she said, but the business/profit/insurance people were still calling the shots. Apparently they had their own criteria.

In desperation, I asked whether I could pay for the procedure myself. After all, it’s just a twenty-minute, noninvasive, outpatient procedure requiring only local anesthetic. “No,” the lead “communicator” replied. The insurance wouldn’t pay until the business people had approved my surgeon in his new position, and their rules prevented a patient from paying for anything covered by insurance. This was so, she said, even through my insurance (Medicare and United Health Care), to my knowledge, have no in-network requirement and claim to cover any licensed provider.

So I needed a simple, routine procedure from a superb doctor just beginning his practice with a new medical group. The insurers wouldn’t yet pay him to treat me, and I couldn’t pay him myself. He simply couldn’t treat me at all until his business and private-insurance overlords gave the go-ahead. That “Catch 22” was one that even Joseph Heller’s famous novel couldn’t have imagined. But this wasn’t satyric fiction; it was and is dismal fact.

The “communicator” on the phone couldn’t say how long the bosses’ approval would take, but her experience suggested at least ninety days. That’s too long to wait for a possible diagnosis of recurrent cancer. So I would have to find another, unfamiliar caregiver, on an emergency basis.

Typically, doctors have at least ten years of higher education and training: four years of college, four years of medical school, and one year each of internship and residency. For specialists like mine, there’s also another year or two of speciality training. Yet people who, like our president, spent a mere four years in undergraduate study of “business” are now telling them not only what to do, but how to do it.

Another surgeon at a major medical institution told me that his business bosses went so far as to “prescribe” a mandatory minimum number of biopsies in another routine diagnostic procedure, regardless of what the physician performing it found or didn’t find. Far from the Hippocratic Oath, whose basic tenet is “Do no harm,” these business bosses demanded unnecessary, invasive steps, with risks of infection and bleeding, for no apparent reason but theoretical risk aversion to protect profits.

If you want a dysfunctional health-care system, be sure to have business-school grads and lawyers, not doctors, run it, telling superbly trained doctors what do do. That’s what turning American medicine into a for-profit business has accomplished.

So yes, this system has mugged me personally. I have to look for another physician to do my simple procedure on an emergency basis. I have to break my bond, at least temporarily, with a superb doctor who has cared for me for a decade. Not once in my entire weeks-long interaction with Valleywise was I allowed to communicate with anyone trained in medicine or health care—not so much as a nurse or hospital orderly. Insofar as letting me deal with practitioners of medicine—real caregivers—Valleywise was a stone wall. And all because we have a health-insurance system that has thrown away the Hippocratic Oath and replaced it with private profit.

My objections to Medicare for All on this blog (see this post and this one) were never based on the substance of health insurance or health care, but on political realism alone. I thought that the coercive effect of wiping out private insurance by law would be a hard political sell. I was right about the coercive aspect of “Obamacare’s” mandate: from the outset it was the principal focus of right-wing demagoguery. Now the courts have killed the mandate. Right-wing litigators are also asking them to do away with the rest of Obamacare, which got over twenty million new patients insured.

Now, having been mugged personally, I’m ready to roll the dice. I’m eager to probe how many others our broken system has mugged like me. I want to see the Hippocratic Oath replace profit as the focus of medicine. I want altruism and caring to become medicine’s moral engines again.

The whole basis of private health insurance is a lie. There is no “market” in health care: you do not “bargain” over sickness, pain, suffering and death. Likewise there is no “market” in health insurance, because low premiums depend on insuring everyone. The rest of the developed world has single national payers for that very reason.

So now I’m looking forward to watching Bernie Sanders and/or Elizabeth Warren handle our absurdly dysfunctional and grotesquely inhumane system of private health insurance. I want to see them burn it to the ground, and I hope to live to dance upon its ashes.

[For a broader take on Medicare for All by humorist John Oliver, click here.]

Endnote: A Word to Doctors

My favorite uncle, long deceased, was a skilled general surgeon. His career was in the United States Navy, where he served in World War II and the Korean War. He and his wife are buried in adjacent graves in Arlington National Cemetery.

Until he retired with the rank of captain, he worked for military pay, under Navy discipline and Navy orders. He never thought of medicine as a business. He joined the Navy not just to serve our country in a time of peril, but to avoid wasting his talent, training and energy doing anything unrelated to medical science or patient care.

When Medicare was first under discussion, my uncle thundered against it as “socialized medicine.” I never understood why he fell so hard for the bosses’ propaganda, but he did. Maybe it was pride in the struggle it took to get to his position. He also thundered mightily against medical interns being paid, unlike those of his generation, starting some time in the late 60s.

Today’s doctors ought to know better. Those whom I’ve known as a patient are far more under the thumbs of business people and insurers than my uncle ever was under the thumbs of superior naval officers. I never heard him complain about superiors second-guessing his medical decisions. But I’ve heard several doctors in elite medical groups complain that their business and insurance overlords treat them as hired hands. And then there are those arbitrary boss-made rules, like a mandatory minimum number of biopsies in a routine diagnostic procedure.

So today doctors have a choice. They can go for the gold and put their careers, their medical groups and their professional discretion into the hands of profit-hungry business people who can get the gold for them—after skimming most of it for themselves. Or doctors can do what Jesus did, throw the money changers out of the temple, and recover their professional dignity, their control over the practice of medicine, and their self-respect. They can’t do both.

There’s no question in which direction today’s private health-insurance system points. It treats doctors as hired hands who must do what the business people and private insurers tell them. It suffocates them with wildly dysfunctional bureaucracies and mutually incompatible computer systems. And it claims, with some justification, that doctors need those dysfunctional bureaucracies and mutually incompatible computer systems to handle all the claims of the many private, for-profit insurers who handle and pay their bills.

As a patient, I know what kind of doctor I prefer. I want the one who puts his or her practice of medicine, professional discretion, and self-respect first. Today, that means accepting a single payer, probably the government, that minimizes its intrusion into medical decisions because it’s a single, coherent organization that doesn’t work for profit but just wants medical care to work.

To be honest, such a system probably also means lower average pay for the medical profession in general. But what patient wants a doctor who works for money, rather than for patient care and the advancement of medical knowledge? And won’t the medical profession be better off with fewer doctors motivated primarily by their pay?

How many students go to medical school for money anyway? Maybe if the government subsidized more of the high cost of their medical training, fewer graduating students would be motivated by high pay just to retire their staggering student debt.

MLK Day 2020

I didn’t want to let this holiday go by without acknowledging the man whom it honors. But the honor is as bittersweet this year as it was last year, perhaps more so. We have endured another year of “leadership” by a man utterly unfit to serve in our government at the highest level, let alone to lead it.

More to the point, the likelihood of Trump being acquitted of the clearest case of treason ever asserted against an American president makes MLK’s absence today all the more poignant. For as the pundit Colbert King pointed out in a recent tribute, MLK was a rare thing in our pragmatic, commercially obsessed United States. He was a moral leader, first for Christians and then for all of us.

We have few or no moral leaders today. Our chief executive is purely transactional. He self-evidently has no moral code or moral compass besides his own personal and financial aggrandizement. Yet no Democrat running to replace him seems to fill that void. Dr. King was practically unique in our history in advocating for equality, justice and freedom as moral values, not just political and practical ones. He was literally unique in advocating their achievement exclusively by nonviolent means.

MLK was shot down by a cold-blooded killer in an act of hate and right-wing extremism. But he was not the only one. So were JFK, who helped save our species from nuclear Armageddon in the Cuban Missile Crisis, and RFK, who had created a task force to rid our nation of organized crime. These three assassinations, all in the 1960s, likely were the historical fulcra of our dystopia and misery today.

Of the three men assassinated, King was the only one who preached a different and better morality. We have no one like him in public life today. Instead, the so-called “evangelical Christians” support a man as far afield from the teachings of Jesus as Donald Trump.

As we come close to destroying our planet out of greed for easy energy, and as we get no farther away from the nuclear self-incineration that we nearly suffered in 1962, we desperately need a moral leader like MLK today. Unfortunately, we have no one who even comes close to matching him, so his memory is all the more poignant this year.

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