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The Journal Gazette

Sunday, September 24, 2017 1:00 am

A single solution?

IPFW panel weighs the merits of radical health care overhaul

TIM HARMON | The Journal Gazette

IPFW Panel discussion

The health care financing panel discussion at IPFW will be broadcast on CollegeTV at 7 p.m. today and again at 6 p.m. Monday.

CollegeTV is available on Comcast (channel 5) and Frontier (channel 30).

The program also may be viewed on CollegeTV's YouTube channel. Search YouTube CollegeTV Fort Wayne.

WBOI-FM will broadcast the discussion at 7 p.m. Wednesday. It's also available on the station's website at

Health care funding is a subject that can make your head hurt. It demands looking at charts and grasping impossibly large numbers. College students have to do that all day long, which may be why none of them seemed to be in evidence at the discussion in a corner of IPFW's Helmke Library led by Andrew Downs, assistant professor of political science, one evening earlier this month.

The primarily middle-aged audience, having acquired the patience and wisdom that comes through years of doctor's visits, sat attentively through the taping as Downs led a discussion of health care's future, centering on whether the United States would benefit from moving to a single-payer health care system. (The discussion airs tonight and Monday on CollegeTV and Wednesday night on WBOI-FM.) The three panelists – IPFW health economics specialist Zafar Nazarov and Drs. Peter Hanley and Jonathan Walker – reviewed the current American system, looked at other countries' approach to health care and outlined some of the arguments for change.

But the health care debate today waits for no man, woman or panel.

The following day, U.S. Sen. Bernie Sanders formally unveiled his Medicare-for-all proposal, with progressive Democratic senators at his back and Republicans instantly complaining about the potential cost. Meanwhile, a Senate committee's effort to make some bipartisan fixes to the Affordable Care Act was unraveling and yet another repeal-and-replace proposal was quietly gathering steam. Last Wednesday, U.S. Senate Majority Leader Mitch McConnell was feeling confident enough about the bill proposed by Sens. Bill Cassidy and Lindsey Graham to announce his intention to schedule a vote this week.

But whether Obamacare is replaced, repaired or left in limbo, the single-payer debate is likely to remain a part of the health care conversation.

“The politics of healthcare are still going to be pretty intense when we get to 2018 and even in 2020, even if legislation is passed,” Brian Tabor, president of the Indiana Hospital Association, said in an interview Wednesday.

A concept widely in use

The single-payer concept guarantees health coverage for everyone, either through government funding or compulsory purchase of insurance. Most Western nations use some variation of that model, Nazarov explained. Great Britain, Canada, Australia and most Scandinavian countries use a model named for British economist William Beveridge in which the government runs hospitals and supplies health insurance for all.

Germany, Japan, the Netherlands, France, Switzerland and Israel use a system similar to the U.S. worker's compensation program originated by 19th-century German Chancellor Otto von Bismarck, Nazarov said. That system, financed by payroll taxes, also guarantees coverage to all.

“Unlike the Beveridge model,” he said, “health care is provided by private entities, but prices and services are regulated heavily by the government.”

Though the U.S. system stresses private health care, it also incorporates elements similar to the Beveridge approach – Medicaid and Medicare – and “the Affordable Care Act actually moved us toward the Bismarck model,” Nazarov said.

Walker argued the U.S. arrangement needs to be rethought.

“We have an incredibly fragmented health care system,” said Walker, long an advocate of the single-payer approach. “With a little bad luck, any one of us could also be left out of the health care system. It makes us pay a huge amount of money for our care. It fails to address fundamental public health issues. It leaves us swamped with useless paperwork and bureaucracy.”

Pointing to a chart showing the percentage of growth in the number of medical managers rising more quickly than the growth in the number of physicians, Walker said single-payer could be the best way to get a handle on the nation's soaring medical costs.

“When you go to see your doctor, you're not seeing just your doctor,” Walker said. “You're seeing all the secretaries, all the administrative personnel, all the government hassles that are tacked onto it. ... About 30 percent of my office staff effort is spent fighting insurance companies and dealing with those kind of hassles and then being told we can't take care of a patient a certain way, or filling out paperwork to get some sort of drug.”

Walker pointed to another chart showing a sudden jump in Americans' life expectancy after age 65 to bolster his argument that a single-payer system like Medicare-for-all might improve  quality of care.

Walker acknowledged many factors could be in play in those outcomes, including the drop in stress some feel after they retire. “But I suspect,” he said, “it's because once you get on Medicare, you suddenly have a fighting chance of getting good access to health care.”

A cardiologist for Lutheran Medical Group and clinical associate professor at IU School of Medicine, Fort Wayne, Hanley agreed some form of simpler, single-payer system would be desirable.

But Hanley, who once practiced in Great Britain, cautioned that some socialist-style features of the British system might not go over well here.

“America's a very disparate place,” he said. “The states do different things, their populations are different. ... I worry about 100 percent government care ... It's a different mindset in this country, so I don't know that you can have the same degree of political involvement as you would have elsewhere.”

Uncomfortable tradeoffs

Though he has long argued for consideration of single-payer systems, Aaron Carroll, an Indianapolis physician, also expressed discomfort at the lack of attention to the tradeoffs involved in a plan such as the one Sanders is proposing.

“A lot of the talk that goes around with single-payer often makes it sound like there's an easy solution to everything, and there is no easy solution with health care, ever,” said Carroll, a professor of pediatrics at the Indiana University School of Medicine.

First, said Carroll, who writes columns for the New York Times and conducts discussions of health care topics online, “covering more people generally will cost more money. That's just baseline. Second, what he's proposing is much more generous than Medicare currently is.”

Administrative savings are a two-edged sword, he said, because “the administrative savings are people's jobs.”

Despite all the oft-cited shortcomings of private insurance obtained through the workplace, eliminating that system would be a large pill for many Americans to swallow, Carroll said.

“Many, many people are happy with their employer-sponsored health insurance,” he said. “When they lose it – they don't like change – there will also be some repercussions.”

Carroll, who once appeared on “The Colbert Report” to advocate for single-payer, said he still believes in the concept. “But no one should be under the illusion that doing so will make everything just automatically cheaper, better and more accessible to everybody.”

Interviewed a few days after the panel, Walker said he knows many questions remain about how a U.S. single-payer system might play out.

But he's glad it's getting more attention.

“Just to get it on the table so people can start thinking about it is a breakthrough,” he said. “I think when people really begin to think about how our health care system works and how much money they spend, they'll be open to considering the advantages of a single-payer system.”

The Hospital Association's Tabor, who was focused last week on the potential problems the Cassidy-Graham bill could create for Hoosier health care, said the Democratic push for single-payer system could be disruptive, as well.

“I honestly don't think that it can be done in the foreseeable future,” Tabor said. “I don't think that all of the effects are fully understood yet.”

A better approach than either of those proposals, he said, is to focus on improving the Affordable Care Act and preserving coverage for the many Hoosiers who receive it through the Obamacare marketplace and HIP 2.0.

“There are ways we can strengthen the system we have,” Tabor said, a system “that encourages a lot of innovation.”

Tim Harmon is an editorial writer at The Journal Gazette.