EPs Advocate for Universal Health Care

Even a heckler couldn't dilute the message James C. Mitchiner, MD, MPH, was trying to impart during his lecture at the American College of Emergency Physicians Scientific Assembly in Boston yesterday. One attendee shouted out twice in opposition to his call for universal health care, but a good portion of the packed room rose for a standing ovation at the end of his talk. In the Colin C. Rorrie, Jr., Lecture, “Health Care Reform Within the States and Beyond,” Dr. Mitchiner came right to the point: “We need universal health coverage,” he said. He noted that the United States' per capita health care costs are three times higher than Canada's, with health insurance premiums increasing 131 percent since 1999. That cost today is $13,375, but by 2019 is projected to be $24,180 a year. From 1970 to 2008, the number of administrators, however, has grown 3000 percent, with six of 10 personal bankruptcies due to medical costs or health insurance charges. “Clearly this is unsustainable,” said Dr. Mitchiner, a clinical assistant professor of emergency medicine at the University of Michigan Medical School. “Everyone must be covered.”ImageThe question Americans should ask themselves is, what is the marginal value of health insurance over public insurance, he said. Private insurance companies' goal is to make money, and they take 20 percent right off the top. “The problem is the insurance companies. We need a plan that is socially conservative and fiscally responsible,” said Dr. Mitchiner, also the medical director of MPRO, Michigan's independent nonprofit quality review organization. “The first thing is to recognize the inconvenient truth of health care in America, and that is much of what we spend on health care doesn't go toward treating and preventing disease,” he said. He said much of the fear and opposition to universal health care is that it is confused with socialized medicine. Although both are is publicly financed, only socialized medicine forces patients to see government physicians in government hospitals. In a single-payer health insurance system, universal health care is publicly financed, but patients can see any physician and visit any private hospital. Dr. Mitchiner said a single-payer system would provide comprehensive coverage for all, reduce administrative inefficiencies, sever the link between employment and insurance, allow consumer choice, and reduce health care disparities. “This is the only plan that would meet all three of President Obama's goals for health care reform: expand access, control costs, and have the freedom to choose our own providers,” he said. Sixty-six percent of the public supports a single-payer health care insurance system, according to a July 28 CBS-New York Times poll. And 64 percent support it even if it means their taxes will rise, he said. Of physicians, 59 percent support that system, and when only emergency physicians are asked, 69 percent advocate a single-payer arrangement. Dr. Mitchiner repeatedly emphasized that this is not socialized medicine, adding that fallacy as the first on his list of myths about universal coverage. The others are: ▪ Myth: Americans don't want a Canadian system. Canada, Dr. Mitchiner said, spends only half of what the United States does, and from an American standard, it is grossly underfunded. The problem in Canada, he said, is the money, not the system. In America, the problem is the system, not the money. Canadians live longer and have lower infant mortality, and there is no evidence that Canadians come here for health care, nor that Canadian physicians have been emigrating here en masse to escape their health care system. Eighty percent of Canadians are satisfied with their health care system, he said, and 95 percent say they don't want to go to a U.S. system. ▪ Myth: If the United States could get market-based medicine to work, it would trump the single-payer system. The current system yields dissatisfied patients and increasing health care costs, he said. ▪ Myth: A single payer would eliminate medical innovation, but no studies support this correlation, Dr. Mitchiner said. The largest single funder for medical research in the United States is the National Institutes of Health, with $30.8 billion in funding this fiscal year. ▪ Myth: Health care reform is politically impossible to enact. But that's what was said about Medicare in 1965, he said, and if Americans only did what was politically pragmatic, the country would never have had suffrage or civil rights. Figure: Dr. James C. MitchinerEmergency physicians need look no further than the state hosting its Scientific Assembly for evidence of how such a system might work. Despite its growing pains, Massachusetts' experiment with universal health care has largely been successful, said Bruce S. Auerbach, MD, the vice president and chief of Emergency and Ambulatory Services at Sturdy Memorial Hospital and the immediate past president of the Massachusetts Medical Society. For many years, Massachusetts has had a free care pool of $200 million, which is “a big bucket of money” to which insurers, hospitals, and others contribute to pay for care for uninsured and underinsured low-income residents. “In many respects, we were well-positioned to do this,” he said. Massachusetts also had a low rate of uninsured, only seven percent, and its insurance system was already highly regulated and mostly covered by nonprofit health insurance, said Dr. Auerbach, also a senior scientist at the Harvard School of Public Health and an instructor in emergency medicine at the University of Massachusetts Medical School in Worcester.Figure: Dr. Bruce S. AuerbachOnce the new system took effect, fewer than three percent of Massachusetts residents were uninsured, and the program saw 419,000 new enrollees since October 2006. The plan incorporates two mandates: one for individuals who have to pay a penalty if they don't join the plan and another for employers of 10 people or more who must pay a fine if they don't offer health insurance. As the demand for care increased, reimbursement to hospitals and physicians also rose, Dr. Auerbach said. ED visits continue to climb, but the trend is lower. “Increased coverage does not relate to a reduction in emergency department visits,” he said, noting that it has added stress on the system by adding 400,000 extra people into an already deficient primary care network. Costs per patient were in line with expectations, he said, and total costs were higher because enrollment in the subsidized program was higher than expected and enrollment in the self-pay program was lower than expected. Cost-control legislation passed in 2008 is expected to help remedy that, he said. The state will hold annual hearings on costs and premiums, create ehealth incentives, and workforce enticements. Dr. Auerbach said state leaders recognize that the future could bring risks, such as reduced benefits, fewer people being covered, hospital and physician income squeezed, and workforce shortages.

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