Health care reform is fantastically messy. No matter how bad and cruel
the current system, it won’t be tossed out for something sleek and
efficient. Reform will be more like adding rooms to a sagging bungalow.
The latest carrier of that message is surgeon and writer Atul Gawande,
in a can’t-stop-reading essay
in the New Yorker, "Getting From There to Here." It’s bad news for
full-blown single-payer healthcare. But as Consumer Watchdog’s Jamie
Court argues persuasively in an OpEd in the Los Angeles Times, it’s all the more reason to allow anyone to buy into Medicare–the familiar and comfortable choice.

Gawande
begins and ends with cruelty: the Canadian woman in labor turned away
at hospital doors, the Australian girl with a lung condition, near
death because she can’t afford a tank of oxygen. 

"In every
industrialized nation, the movement to reform health care has begun
with stories about cruelty," he writes. "The stories become
unconscionable in any society that purports to serve
the needs of ordinary people, and, at some alchemical point, they
combine with opportunity and leadership to produce change." The rest of
the industrialized world arrived at universal health care in fits and
starts that "branched" from what was already begun.

The
U.S. has not pushed forward, and now is falling back, in part because
opponents of change keep dragging out the Bolshevik card.

From Gawande:

"[W]herever the prospect of universal health insurance has been
considered, it has been widely attacked as a Bolshevik fantasy—a
coercive system to be imposed upon people by benighted socialist master
planners. People fear the unintended consequences of drastic change,
the blunt force of government. However terrible the system may seem, we
all know that it could be worse—especially for those who already have
dependable coverage and access to good doctors and hospitals."

What,
then, could be more dependable and offer more choice than Medicare?
It’s not perfect, it’s got financial issues, but almost no one over 65
would give it up. It’s also fixable, far short of a complete makeover.

As Court says:

"My parents can get Medicare, so why not me? Americans should not have
to turn 65 years old or become disabled to have access to a public
healthcare program that controls overhead costs, provides broad,
affordable access to care and protects patients against big bills.
President Obama should open Medicare to all Americans who lose their
jobs, cannot afford private health insurance or simply prefer it to
private insurance or an HMO."

"Critics contend that Medicare pays doctors so little that most
physicians won’t accept the coverage, and that it is too bureaucratic
and financially unstable. Medicare does use its size to drive down what
doctors and hospitals are paid. However, the Medicare Payment
Advisory Commission reports that 97% of physicians accept new Medicare
patients, with 80% taking all or most patients, which is comparable to
HMO acceptance rates. And with the massive consolidation of insurance
companies and of HMOs, doctors and hospitals report to our group that
Medicare payments are often as generous, if not more generous, than
those of HMOs and private plans — and received with less hassle and
more consistency. Studies by AARP and the Commonwealth Fund also show
that Medicare patients are more satisfied with every aspect of their
care than patients with private plans."

Patient
satisfaction is what scares the dickens out of private, for-profit
insurance companies and their army of lobbyists, who know that they
can’t keep their excess profits, bloated corporate pay and armies of
care-denying middlemen in a competition with Medicare. So they’ll pound
on the financial issues, issuing warnings of Medicare’s impending
bankruptcy. Not likely, says Court, because the solutions are in front
of us, and President Obama:

"Predictions of its impending bankruptcy mostly have to do with the fact
that the program serves the sickest and neediest patients in the system
without a proper revenue base and in an era of costly techno-medicine.
There are a number of ways to help solve the funding problem.

First,
Obama’s promise of new technology for better medical record keeping
should limit unnecessary or duplicative procedures. Obama also must
grapple with Medicare’s unintended incentives to doctors to do too many
costly procedures at the end of life that only prolong life but do not
improve quality of life. Tom Daschle, the new secretary of Health and
Human Services, has already made this a priority by calling for doctors
and hospitals to be paid for performance rather than by the number of
procedures they perform or drugs they prescribe.

"Bringing younger and healthier patients into the Medicare risk pool
also would stabilize the program’s funding. They don’t use as much
medical care as older and sicker patients, so their payments would
offset the cost of care for the sicker ones. Allowing employers to
offer Medicare is one way to widen the risk pool. Payroll deductions
for Medicare would be less than what the average employer and employee
now pay, according to congressional research."

Gawande
lives and works in Massachusetts, and admires the state’s attempt to
insure everyone within a partially  regulated system of private
insurers. He must have read, and drawn from, a 2007 academic book by
history professor Paul Dutton, "Differential Diagnoses," comparing the
similar health insurance problems–and sharply diverging solutions–of
France and the United States. 

Dutton shows at length how France
also "branched" from an individualistic, private and  and
employment-based health care system into one that cares for nearly all
residents, regardless of job status. But France started with mostly
public or university-based hospitals–and without the intense Cold War
baggage that reduced U.S. arguments for government responsibility to
"Socialism vs. Americanism."

Though Dutton doesn’t make much
note of it, France subsidizes doctor education, allowing physicians to
begin practice without hundred of thousands of dollars in debt. France
also ducked the bane of the U.S. system: the increasing and
uncriticized ability of private insurers to price out of the market–or
exclude altogether–anyone ill or likely to become ill.

So
instead of France’s highly regulated and only semi-private health
insurance aimed at inclusion, judged by U.N. health experts to be the
the world’s best, the U.S. has a sharply split and incomplete system.
There’s government-funded care for the the very poor (Medicaid) and the
elderly, with private, for-profit and very choosy corporations
controlling the rest. The middle class ends up badly insured, uninsured
or clinging to disappearing employer policies.

Gawande’s admiration of the Massachusetts experiment stems from its reductions of personal agony: 

"For the past year, I haven’t had a single Massachusetts patient who has
had to ask how much the necessary tests will cost; not one who has told
me he needed to put off his cancer operation until he found a job that
provided insurance coverage. And that’s a remarkable change: a glimpse
of American health care without the routine cruelty."

But
Massachusetts started with a much smaller percentage of uninsured
residents than the nation as a whole, and Gawande acknowledges that
rising unemployement and insurers’ constantly rising premiums threaten
the reforms. And he sees a mix of private and public, messy as it would
be, as an improved branch on a familiar path. It’s change Americans can
accept personally, not just believe in abstractly.

Or, as Jamie Court concludes:

"With Medicare as the public option in his healthcare plan, the
president could increase its buying power to further reduce
expenditures. Obama-care should make Medicare as big as Americans want
it to be."