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How Universal Coverage Could Change Emergency Medicine, and Vice Versa

      The political changes of the past year have made universal health care coverage in the United States a possibility for the first time in a generation, and a realistic possibility for the first time in history. The White House's newly created Office of Health Reform (OHR), however, needs to run a formidable gauntlet of interested parties to getting their way in Congress. Organizations that helped obstruct the Clinton administration's reform effort in 1993 were also represented last March 5 at a presidential health forum. Conspicuously absent from this gathering, and underrepresented in the national debate, is the perspective of the specialists who already, in the words of one emergency physician, “basically live in a single-payer world.”
      Emergency physicians since the passage of the Emergency Medical Treatment and Labor Act (EMTALA) have been doing what their colleagues in other fields will do if a federal reform bill goes through, and what all physicians do in most other developed nations: care for all comers regardless of insurance or financial status. Under EMTALA, members of this specialty “carry by far the burden,” says Sandra M. Schneider, MD, professor and chair emeritus of emergency medicine at the University of Rochester and current vice president of the American College of Emergency Physicians (ACEP). “Lots of articles show that emergency physicians probably take care of 10 times the uninsured rates of any other specialty.”
      “The paradox that we face in the emergency care system in the US,” says Arthur L. Kellermann, MD, MPH, associate dean of emergency medicine at Emory University and co-chair of the Institute of Medicine (IOM) Committee on the Consequences of Uninsurance from 2001 to 2004, “is that it's the part of the health care system that we value so much that it's the only arena of health care … that everyone in this country is legally entitled to, [yet] we value it so little that we have never made provisions to adequately support that system.” This IOM committee's report cited widespread emergency department (ED) crowding, due in part to many patients' inability to obtain timely primary care anywhere else, among the many reasons why universal coverage must become a national priority.
      Committee on the Consequences of Uninsurance
      Insuring America's Health: Principles and Recommendations.
      ACEP President-elect Angela Gardner, MD, addressing President Obama directly in a recent blog entry, describes the specialty's circumstances in blunt terms: “Emergency physicians are not paid for that care 40% of the time. I dare you to name another specialty that donates 40% of their income to charity care.”
      • Gardner A.
      White House Report on Health Reform , March 30, 2009.
      Universal coverage, say physicians who follow the issue closely, could remove barriers, bottlenecks, and disincentives that currently induce many Americans to avoid or delay obtaining primary and preventive care, only to end up in the ED when other care is unavailable or when a problem progresses too far to be ignored. Experience in nations already providing universal coverage suggests that fears of exacerbated ED overutilization are unrealistic.
      But not all schemes achieve the desired effects. “Universal health care for emergency medicine is a double, maybe triple-edged sword,” comments Dr. Schneider: beneficial in reducing the burden of EMTALA's unfunded mandate and increasing the proportion of ED visits resulting in payment, but capable of backfiring if primary care providers end up refusing a new public insurance card, as some physicians now refuse Medicare, Medicaid, and the state-level plans created in Massachusetts and Tennessee. Subpar payment rates, Dr. Schneider says, would preserve the disincentives that shunt nonemergency patients into EDs, and newly insured patients would no longer be as likely to delay ED visits for fear of backbreaking costs. The question is no longer whether to institute universal coverage, as the IOM committee called for in 2004; it's what kind.
      Although crowding, boarding, ambulance diversion, shortages of on-call specialists, malpractice abuse, and other problems plaguing the nation's EDs have too many causes for universal coverage alone to address all of them, a move toward meaningful reform–one that achieves the trickier goal of true universal access–should benefit the emergency medical system in direct and indirect ways. Unfortunately, the US currently stands only an uncertain chance of making such a move. To date, some of the voices in the debate who perceive serious change as a threat to their interests have been shouting the loudest, and emergency physicians are only beginning to be heard.

      A Long Drum Roll and Several Long Shots

      Before the US gives all residents access to care on a broader, more systematic basis than EMTALA calls for, the White House and Congress face decisions about funding, administration, eligibility for different levels of coverage, the disposition of the existing system, and the role of the public sector. Viewing health care costs and inequities more as factors contributing to national economic stagnation than as expensive challenges to be postponed until the financial crisis passes, President Obama has made systemic reform a priority for his first year in office. The specific legislative package remains undetermined at this writing.
      Though the President has previously said that a single-payer system would be his ideal preference if the reform process were starting from scratch
      Barack Obama on single payer in 2003 (video excerpt: then-Sen. Obama's speech to the Illinois AFL-CIO, June 30, 2003) Physicians for a National Health Program, June 4, 2008.
      as the most effective way to control costs and realign incentives to benefit patients, at this writing the White House is not backing either of the major single-payer proposals before Congress: HR 676, introduced by Rep. John Conyers (D-MI) and 93 House co-sponsors at last count, or the American Health Security Act (HR 1200), introduced by Rep. Jim McDermott (D-WA), with a Senate counterpart (S 703) introduced by Sen. Bernie Sanders (Ind.-VT).
      Instead, the legislation likely to emerge from OHR deliberations (including over 3,200 Health Care Community Discussions aimed at eliciting local citizen opinions) and committee negotiations will maintain the existing insurance system while banning some of private insurers' more objectionable practices (eg, denial of coverage for preexisting conditions), reducing waste and fraud in Medicare, and supporting other measures believed to improve the benefit/cost balance: preventive care, health information technology, and comparative effectiveness research. The most transformative feature, considered a sine qua non by some commentators but dreaded by insurance interests and their political allies, is a public alternative plan.
      The public option, as advocated by Jacob S. Hacker, PhD (professor of political science at the University of California at Berkeley, co-director of the Center for Health, Economic, and Family Security, and fellow at the New America Foundation), is intended to extend access to the rapidly expanding population segment not currently covered through employment and unable to afford private coverage. Since both these patients and insured patients now contribute to ED overuse, the reforms would theoretically benefit emergency medicine by reducing the tide of inappropriate but unavoidable visits. The public plan would wield enough bargaining power to help restrain systemic costs.
      This component is intended to be “Medicare-like—national, governmental, and built on Medicare's basic infrastructure. But it should not be Medicare,” as Dr. Hacker wrote in the New England Journal of Medicine.
      • Hacker J.S.
      Healthy competition — the why and how of ”public-plan choice.”.
      It would have broader benefits, a separate risk pool, better financial rewards, and separate administration from the agency with regulatory authority, so that “the referee [does] not have a player in the game.”
      President Obama reiterated his support for “an affordable basic benefit package” including the public option in a letter to Senators Kennedy and Baucus on June 2. “I strongly believe that Americans should have the choice of a public health insurance option operating alongside private plans,” he wrote. “This will give them a better range of choices, make the health care market more competitive, and keep insurance companies honest.”
      • Brown C.B.
      Barack Obama may support insurance mandate.

      The full text of the President's letter appears at http://www.politico.com/static/PPM110_090603_health_care.html. Accessed June 13, 2009.

      Assuming Obama's plan retains its public option when officially proposed, this feature will almost certainly resemble Medicare in 2 critical respects: it is likely to outperform the for-profit insurance industry dramatically in controlling overhead, and it is certain to be a magnet for alarmism about “socialized medicine” from the political right, just as Medicare was in the 1960s.
      • Eskow R.J.
      ”Operation Coffeecup”: Reagan, the AMA, and the first 'viral marketing' campaign … against Medicare.
      Sens. Tom Coburn (R-OK) and Richard Burr (R-NC) have announced a competing Patients' Choice Act, emphasizing health savings accounts, a tax credit, and state insurance exchanges (with no mandate or incentive for insurers to participate) rather than a substantive federal role. It would also end tax breaks for employer-supplied coverage and attempt to control cherry-picking through “a non-profit, independent board to risk adjust among participating insurance companies.” With little chance of passage in a Democratic-majority Congress, this bill's chief effect will probably be to position Republicans as unopposed to reform in general.
      Rival bills currently being drafted by Senate panels differ on the critical issue of the public plan. Sen. Edward Kennedy (D-MA), who chairs the Health, Education, Labor and Pensions Committee, joins Obama in supporting a public option, with pay rates positioned between those of Medicare and private insurers; House committee leaders are drafting a similar proposal. Finance Committee chair Sen. Max Baucus (D-MT) has been working with Sen. Charles Grassley (R-IA), who claims “we cannot afford the public health plan we have already” (referring to Medicare), on bipartisan legislation lacking that component. A possible compromise proposal would postpone structural reform, creating a public plan only if the private system fails to extend affordable coverage to the full population in 5 years.

      Grand Canyon, Dead Ahead

      Advocates of either “Obamacare” or a single-payer plan hope to revise the narrative that has framed the issue for decades, linking any publicly guaranteed coverage to excess costs and obstructive bureaucracy, and replace it with a new story--one grounded in the recognition that excess costs and obstructive bureaucracy are exactly what the private insurance system has already given us. “It's not 1993. Don't talk about Harry and Louise,” says Dr. Kellermann, paraphrasing the one-liner offered by Sen. Sheldon Whitehouse (D-RI), then repeated by President Obama, at the March 5 forum. “Think about Thelma and Louise. If we keep going straight ahead, we are going over the cliff. So you can turn the wheel to the left, you can turn to the right – but straight ahead can't be an option.”
      The reason the US still has a system that leads the world in expenditures while leaving some 46 million uninsured and lagging behind the rest of the developed world in health outcomes,
      • Davis K.
      • Schoen C.
      • Schoenbaum S.C.
      • et al.
      Mirror, mirror on the wall: an international update on the comparative performance of American health care. Commonwealth Fund, May 15, 2007.
      Dr. Kellermann believes, is economics. “There's an old saying in Washington,” he notes, “that the reason why we never do fundamental health care reform is that the status quo is everyone's second choice. All the different players have their agenda, and if they don't get their way, they say, ‘Well, don't take away what I've got.' I think that emergency physicians, more than any other group, need to say loudly, clearly, and repeatedly, ‘The status quo has to be everybody’s last choice.' We are driving towards a fiscal cliff. Every year millions of additional Americans are losing coverage and losing access to care, and we see the crumbling of the most critical element of the health care system we have, which is the emergency care system. … The status quo has to be completely off the table.”
      As economist Robert Reich
      • Reich R.
      The only sure way to fund universal healthcare.
      and the Harvard team of David Himmelstein, MD, and Steffie Woolhandler, MD, MPH,
      • Woolhandler S.
      • Himmelstein D.U.
      Paying for national health insurance-and not getting it.
      have pointed out, the status quo is not only wasteful but severely regressive, offering the lion's share of an estimated $246 billion annual tax break to the people least in need of it, those in upper income brackets, while relegating the low-paid, the self-employed, and employees of firms too small to provide coverage to the lowest status in the system, either uninsured or underinsured. Dr. Kellermann notes that even the ostensibly insured population is at risk: “The percentage of people with employment-based health insurance [who] have a deductible of more than $1,000 per year has gone from 1% to 18%. And in small firms it's about one in 3. Well, if you've got to pay $1,000 out of pocket before your insurance pays a dime, a typical ED visit is a lot less than $1,000; you're effectively uninsured for your emergency care … and oh, by the way, you'll probably wait a lot longer than you should, fearing that several-hundred-dollar charge, and end up sicker than you need to be.”
      The ethical code implicit in emergency practice, Dr. Kellermann notes, contrasts sharply with the incentives that so often determine hospital policy. Patients with actual emergencies and patients arriving in the ED for lack of other options, he says, both end up “competing for beds with far-better-paying elective patients who have been prescreened for good insurance coverage and vetted by the institution, and therefore the hospital can make more money per day or per bed on elective cases, on average, than emergency cases. So while we in emergency medicine are trained to the concept of ‘worst first’ triage—the sickest or most injured get the most immediate attention—when it comes time to accessing a hospital bed or even, tragically, an intensive care unit, it's not always worst first; it's often ‘Who pays the highest margin gets the priority.' ”

      Diagnosing a Systemic Disorder

      Emergency physicians are “pretty widely recognized now as the master diagnosticians in the health care system,” says Dr. Kellermann; the ED is “one of the rare areas in medicine where we've actually improved quality and dramatically lowered cost at the same time.” Yet this clinical acumen coupled with experience in caring for the un- and underinsured has not translated to visibility in the policy debate. Emergency medicine appears in the report of last March's White House forum only as the setting for the rendering of “extraordinarily expensive” care to patients whom a more rational system would treat elsewhere.
      “By and large,” says Dr. Schneider, “we, who take care of almost 120 million patients per year, have been excluded from the conversations about health care.” Primary care physicians have been appropriately represented, but the organizing concept in the primary care specialties, the “medical home,” strikes her as a feel-good phrase rather than a credible solution, depending as it does on existing insurance. “Everybody has this idea that the uninsured are these lowlife people who can't get or keep jobs,” she comments. “They forget that the bulk of the uninsured are people who are working for themselves, people whose companies don't cover their insurance … college students who just graduated and haven't quite gotten a job yet, or are working at a per diem-type job until their job starts. … Millions of people will go in and out of the insurance market each year, and those people will be the ones that don't have a medical home.”
      The dominance of employer-based coverage, Dr. Schneider observes, was more a historical accident than a purposeful choice. During the World War II wage freeze, when the War Labor Board ruled that health insurance was exempt from controls, coverage became an allowable alternative to raises for attracting or retaining workers. Through the economic expansion of the Truman Administration and afterward, this minor perk evolved into a standard benefit. “This country didn't sit down and say, ‘Gee, let's create a health care system,' ” she says.
      As efforts to design a purposeful national program were repeatedly shot down--sometimes by opponents who feared racial desegregation in federally regulated hospitals as much as they feared “socialized medicine”--measures such as the 1954 Revenue Act (exempting employer contributions to health plans from taxable income) and the 1965 Medicare/Medicaid legislation created the policy patchwork that substitutes for a coherent system. Considering the clout of the multibillion-dollar industry that has developed as a consequence, Dr. Schneider is frankly pessimistic about the prospects for change beyond the “BandAid” level.
      “The worst case scenario is probably the one we have,” comments Dr. Schneider. “What's stopping us from appropriate health care reform is that everybody is trying to protect their turf, and the individuals who are writing health care legislation are very cognizant of this. … The best-case scenario would be some system that would be brave enough to re-engineer medical care. We're not going to have that. We're going to have the worst case scenario, where everybody's going to be listening to special interests and nobody's going to want to tick off any particular group, and so the people who are going to lose are the people who don't have the strongest voice in Washington. And that's the patient.”

      Exit Harry and Louise, Please

      The Harry and Louise paradigm was the work of the Health Insurance Association of America, rechristened America's Health Insurance Plans (AHIP) when it merged with the American Association of Health Plans in 2003. AHIP president and CEO Karen Ignagni was a prominent participant in the March forum, giving reform advocates reason to suspect that an industry fix might be in. As a recent Associated Press profile notes, Ignagni had nothing to do with the Harry and Louise campaign; she beat out Chip Kahn, the lobbyist behind the ads, for the top position when the lobbies merged. OHR Director Nancy-Ann DeParle singled out Ignagni's input as a positive sign: “I knew things were different this time around when Karen said, ‘We want to work with you … You have our commitment to play, to contribute, and to help pass health care reform this year.' ”
      • DeParle N.
      White House Forum on Health Reform Report (blog post, White House Briefing Room), March 30, 2009.
      Shortly after the insurance industry representatives agreed to cooperate with the President, however, a Washington Post health blog leaked details of a PR campaign by North Carolina Blue Cross/Blue Shield to disparage Obamacare's public option.
      • Connolly C.
      North Carolina's Blue Cross Blue Shield trying to kill key plank of Obama plan.
      Allies of the President, advocates of single-payer and other structural reforms, and commentators such as economist Paul Krugman immediately seized on this incident as a new instance of Harry-and-Louising and a sign that AHIP's claims of good faith were untrustworthy.
      Debate has also been skewed by well-funded parties characterized by media watchdogs as Astroturf groups: Conservatives for Patients' Rights, led by former Columbia/HCA executive Rick Scott (ousted after his firm pled guilty to fraud charges and paid a record $1.7 billion in fines) and CRC Public Relations, the same firm that gave rise to the term “swiftboating” by spreading untruths about Sen. John Kerry in 2004;

      See also Eggen D. Ex-hospital CEO battles reform effort. Washington Post, May 11, 2009 [http://www.washingtonpost.com/wp-dyn/content/story/2009/05/10/ST2009051002320.html].

      the Center for Medicine in the Public Interest (CMPI), a 2-man operation linked to another public relations firm and funded by pharmaceutical companies;
      • Brownlee S.
      • Lenzer J.
      Stealth marketers: are doctors shilling for drug companies on public radio?.
      and Republican consultant Frank Luntz, whose memo “The Language of Healthcare 2009” (leaked to the nonpartisan blog Politico
      • Allen M.
      Frank Luntz warns GOP: Health reform is popular.
      ) gives pointers on how to kill systemic reform by framing it in off-putting language while appearing to embrace change in nonspecific terms. The commercial aired by Scott's group has come under fire from the Annenberg Foundation's FactCheck.org, among others, for factual errors and misrepresentation of sources' opinions. The Columbia Journalism Review has detected Astroturf tactics involving fake letters to the editor of a small-town newspaper.
      • Lieberman T.
      A Laurel to the Eagle-Tribune: paper gets Astroturfed and smells a rat.
      The CMPI has attempted to blur the line between a public option and “government-run” systems, offering anecdotes of patients who had to wait for procedures in Canada but encountered no waiting at private US facilities.
      But the battle of anecdotes works both ways, says James C. Mitchiner, MD, MPH, of Emergency Physicians Medical Group and Saint Joseph Mercy Hospital in Ann Arbor, Mich., who is active in Physicians for a National Health Program (PHNP): “for every anecdote that somebody can tell me about Canada, I can think of about ten anecdotes about people who come to the emergency room who have problems because they didn't have health insurance.”
      The Los Angeles Times, for example, recently publicized a case in which Aetna and Anthem rejected a California resident's application for coverage on preexisting conditions grounds, her “condition” being a series of automobile-inflicted injuries that had been fully covered when she lived in Canada.
      • Lazarus D.
      Canada's healthcare saved her; ours won't cover her.
      CNN drew attention to the case of another woman who died of deep venous thrombosis while lying unattended on the waiting room floor of a psychiatric emergency department in Brooklyn.
      • Snow M.
      • Fantz A.
      Woman who on died on hospital floor called “beautiful person”.
      In the wake of such publicity (not to mention Michael Moore's Sicko, a first exposure to overseas health care systems for many Americans), Harry and Louise may have finally, as they say around network TV, jumped the shark.
      The lobbyists' argument against a public option includes an element of implicit schizophrenia. If both private and public payers are available (as in the likely Obama/Kennedy proposal) and patients have a choice between them, insurers' assumption that private entities always outperform government makes scare tactics unnecessary: should the public option indeed produce more inflexibility and delays than the private option, the latter will prevail in the marketplace. A public option that functions well for patients, on the other hand, would be a strong competitor against the private system, either outcompeting the Blues and other insurers or spurring them to improve their performance, to patients' ultimate benefit. The logic underlying the Blues' campaign appears equivalent to “A public plan would be terrible. Patients, you'll hate it. We're afraid to compete with it.”

      This Might Work; Pick Anything Else

      To Mitchiner, a single-payer system is more than a logical answer to the conundrum of costs and coverage. It's the logical extension of the practice style of emergency medicine, with priorities emphasizing effective care rather than cost-shifting and cherry-picking.
      “Emergency physicians: we basically live in a single-payer world,” Dr. Mitchiner observes. “We see everybody regardless of what insurance they have, or even if they have no insurance … and if you think about it, emergency doctors get a single check every month regardless of whether they're employed by the hospital or, like me, they work for a group. I could only imagine how much bigger that check would be if we got paid on 100% of the patients we saw, even if it was at Medicare rates.” Doing away with administrative expenses for billing private insurers, he notes, would lower expenses for running an emergency practice. “And then finally we'd save a lot of money on the other end: at the end of the month we'd have a lot left over in our check because we wouldn't be spending $1,500 or more per month for health insurance premiums, copays, deductibles, dental care, prescription eyeglasses, prescription drugs, and so on. So I think emergency physicians would come out ahead with a single payer.”
      On the utilization side, Mitchiner sees no evidence from single-payer nations like Canada and Taiwan that patients are overusing EDs relative to the United States. In studies of Canada and the US, he says, “they're both about 38 to 39 visits per 100 population.” In Taiwan, which adopted a single-payer system in 1995, “by 1997 they have gone from 57% of the population insured up to 97%, and there was no statistical increase in the ED utilization. As for payment rates … primary care doctors in Canada have actually done better in the last 12 years in terms of their improved income relative to the primary care doctors in the US.”
      Citing polls indicating heavy popular support for public universal coverage, Dr. Mitchiner encourages colleagues to advocate a full single-payer restructuring despite the political odds. “If we did everything in this country based on what was politically pragmatic,” he contends, “we never would have gotten civil rights passed; we never would have got the Voting Rights Act passed. There are certain things that just aren't popular, but they become so over time” -- the most directly comparable case being Medicare.
      Robert C. Stone, MD, assistant clinical professor of emergency medicine at Indiana University, director of Hoosiers for a Commonsense Health Plan, and state coordinator of the Indiana chapter of PHNP, speaks frequently to voter groups about the realities and myths of different systems. He finds that Medicaid refusal by other specialists commonly obstructs patients' access to care in rural areas. From the ED perspective, he says, where physicians do not exercise that dubious privilege, “a real universal plan [where] everybody's going to be paid closer to a Medicare rate than a Medicaid rate” is “kind of a slam dunk … if we got paid for every patient at a Medicare rate, and our billing costs went down 75 to 80%, it would just be a huge boon to us, financially as well as heartache-wise.”
      Certain common beliefs about foreign universal coverage plans strike Dr. Stone, a self-described “evidence-based guy,” as misleading. He readily acknowledges that for “our English-speaking brethren in Canada and England … waiting times are issues,” but he points out that this is not the case in the German, Japanese, Taiwanese, and Swiss systems; generalizations about delay being inherent in all universal systems are untrue, failing not only to consider multiple systems but to ask the key question, “waiting for what?” The waiting time differences commonly cited to Canada's disadvantage involve certain elective procedures, not emergency care; waiting times to get appointments in the US are extraordinarily long even for insured patients, and the Canadian system's transparency allows patients to look up individual physicians' appointment delays online and plan accordingly. The chief reasons Canadian waiting times draw attention, Dr. Stone says, are that well-funded opponents overpublicize them and that in quality comparisons with the US, according to Commonwealth Fund metrics, Canadians “don't have anything else to complain about.”
      Dr. Stone also debunks complaints that the care provided to undocumented residents stresses the emergency medical system and would worsen crowding under universal coverage, not only because such positions frequently involve xenophobia and racism but because “the best data I've seen” suggest that undocumented workers, counterintuitively, actually subsidize care for the rest of Americans.
      • Mohanty S.A.
      • Woolhandler S.
      • Himmelstein D.U.
      • Pati S.
      • Carrasquillo O.
      • Bor D.H.
      Health care expenditures of immigrants in the United States: a nationally representative analysis.
      • Newton M.F.
      • Keirns C.C.
      • Cunningham R.
      • et al.
      Uninsured adults presenting to US emergency departments: assumptions vs data.
      The undocumented population pays sales tax and property taxes (through rent); many have Social Security numbers and pay into that system and Medicare as well. But what they pay into the system they rarely receive back, being relatively healthy (“the diabetic with only one leg,” Dr. Stone notes, “has a hard time crossing the river”) and reluctant to visit physicians because of both economics and fear of discovery by immigration officials.
      The bill he favors, HR 676, specifically addresses residents, not citizens. Dr. Stone advocates this breadth of coverage on the humanitarian grounds that “it's just the right thing to do to take care of everybody and not try to get into the enforcement hassle, figuring out who's got the cards”--and on common sense public health grounds, considering ongoing epidemics of tuberculosis, H1N1 influenza, and other infectious conditions.
      Another belief that is counterproductive out of context, Dr. Stone contends, is that Medicare is going broke: an obvious ill omen for proponents of any reform option resembling it. He counters this frequent objection with data contrasting the doubling of private premiums between 2000 and 2008 (combined with increased copays and deductibles, ie, less real coverage for twice the cost) against the slight rise in Medicare costs--with no benefit cutback, no change in the Medicare payroll tax, better cost control, far lower overhead, and actual increases in emergency physicians' reimbursement in most recent years despite annual warnings of cuts (and real cuts affecting other specialties). “Our entire system's unsustainable; it's not just Medicare,” he says, and Medicare is providing better value than private plans. “If you want to really solve Medicare going broke, you've got to deal with the whole system … put everybody in Medicare, because we'll save so much money that way.
      “Ultimately,” he continues, “the great ‘pro’ in favor of single-payer is that it really is the only system on the table that has really good cost control. And the great ‘con’ is, it is the only system on the table that has really good cost control. Because, as Paul Krugman said [a few] weeks ago, ‘What the rest of us call health care costs, they call income.' ”
      • Krugman P.
      Harry, Louise and Barack. New York Times, May 10, 2009.
      All the arguments in favor of single-payer have not outweighed the lobbies' clout, laments Dr. Stone. He notes that Sen. Baucus, who garnered headlines on May 5 by calling security on a succession of activists from PNHP, Single Payer Action, and Health Care Now who objected to the exclusion of single-payer from consideration by his committee,
      • Nichols J.
      Baucus healthcare plan: arrest doctors, nurses. The Nation, May 13, 2009.
      is the recipient of hefty insurance and pharmaceutical campaign contributions--more than any other Democrat in Congress according to Consumer Watchdog, using Federal Elections Commission data compiled by the Center for Responsive Politics.
      Health insurers & drug companies contributed $5.5 million to top 10 Senate and House recipients since 2005. Consumer Watchdog, March 9, 2009.
      • Adams J.S.
      Baucus, Obama say single-payer not achievable. Great Falls Tribune (Montana), May 19, 2009.
      Closed-door hearings that exclude not only obstreperous protesters but respected national commentators (Dr. Stone mentions researchers Himmelstein and Woolhandler and former New England Journal editors Arnold Relman, MD, and Marcia Angell, MD, all absent from Baucus's 15-person hearing on May 5) strike him as a sign of weakness: “Let these people sit at the table, unless you're afraid of what they're going to say.”

      The State of the Art of the Possible

      Describing the gap between a logical solution and political possibilities, Stone paraphrases Himmelstein's characterization of his economic analysis as a medical consultation to the body politic: “Himmelstein says, ‘I’m a doctor. I'm going to recommend to my patients what I think is the best thing based on the evidence, based on the data. I'm going to push for single-payer and let the politicians sort out the compromises that need to be done.‘” Though he personally prefers an ambitious homerun swing on the issue, Dr. Stone (mindful of the axiom “politics is the art of the possible”) understands that the White House wants to play it safe. “Doing the Obama plan as it is on the table right now, they think, is much more politically feasible, whereas clearly to go for single-payer right now would be a much tougher political fight.
      Dr. Kellermann, acknowledging that his position disappoints some colleagues, finds that the strengths of single-payer are a political moot point. “Single-payer has been so thoroughly trashed in this country over the years by the insurance industry and provider groups and doctors, to the point where it's almost hard-wired into a large majority of Americans to distrust that model. It may happen someday, as Churchill famously said, ‘after we’ve exhausted all the alternatives.' Or, if we ignore the problem long enough and the system implodes, it'll be the only option left. … It has its champions in the country, and they have very compelling arguments, but the polling I've seen from both Republican and Democratic pollsters [indicates] that we have nowhere near a majority of Americans that are ready to support it. It's going to be a heavy lift to get even comprehensive reform through, much less reform at that level.”
      A viable public option strikes Dr. Stone as the indispensable aspect that would make “Plan B” Obamacare supportable. Dr. Kellermann describes the public option optimistically as the element that emergency physicians should and can put their weight behind. “I think a pluralistic system that combines the strengths of both [the public and private sectors] is the American way … and even that is going to be tough to do,” he says. “I think that's the most transformational and yet reachable objective, and it's not even clear that that will be on the table once the deals start getting made. … I think emergency physicians should look very hard at the public health insurance option, and I would hope that we'd get behind it, because I think that it will be good for their patients and good for emergency medicine.”
      With its own lobbying energies largely focused on the Access to Emergency Medical Services Act (H.R. 1188 and S. 468) addressing boarding, revenue, and on-call incentives, ACEP has yet to take a formal position on the various restructuring proposals, though its Board of Directors is working on position papers regarding systemic reform. If opinions within the specialty frame the choice chiefly as single-payer versus public option Obamacare–while the choice in Washington may ultimately be public-option Obamacare versus something calling itself a reform while offering little real change–this speaks volumes about the distance between the dominant assumptions inside the Beltway and the realities of medical practice nationwide.
      Dr. Kellermann, meanwhile, balances pragmatism, patriotism, and exasperation: “There's more than enough money in the US to give good care to everybody. I can't believe that we're dumber than every other country on Earth--countries covering everybody in their population and getting better health care for less money than we are. I'll be damned if I think they're any smarter than us. They have systems that are more rational in how they deliver and organize health care; we can do the same thing in this country. We ration more ruthlessly and more aggressively on a day-to-day basis than any other industrialized nation, but we ration based on the ability to pay, and we sell on the basis of what the market's willing to bear, without necessarily regard for whether it's what the patient really needs.” Something else patients might need to see soon would be a conversation between the president whose election represented a mandate for substantive change and the physicians with immediate, visceral knowledge of where that change is needed.

      References

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        • Committee on the Consequences of Uninsurance
        Insuring America's Health: Principles and Recommendations.
        National Academies Press, Washington, DC2004
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        White House Report on Health Reform , March 30, 2009.
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