Back in 1997 the Drs. Scriber moved to another city having accepted faculty appointments at another university. I selected a physician who was in my insurer’s network. I was most happy with my care: my plan, my doctor, his staff. After a couple of years, however, he announced that he was going back to school. He said medicine was increasingly becoming a business and he needed to retrain as an MBA! A couple of years after that, I observed that he had opened a new private practice. I inquired: could I sign up and have him be my doctor again? No, was the answer. He was not accepting medical insurance. In short, if you had the money, you could buy his services.
My doctor’s business decision was a sad commentary on the state of health care in America. It was also a harbinger of what is increasingly coming our way. Below I cover a report on that trend and then cover another op-ed making the case for a better way.
Mayo Clinic prefers patients with private insurance
The Minneapolis Star Tribune reported a few days ago that Mayo to give preference to privately insured patients over Medicaid patients. This morning the Daily Star reprinted part of the report, subtitled Pushback on Medicaid, Medicare part of a trend. Here are selected snippets.
Mayo Clinic’s chief executive made a startling announcement in a recent speech to employees: The Rochester-based health system will give preference to patients with private insurance over those with lower-paying Medicaid or Medicare coverage, if they seek care at the same time and have comparable conditions.
The number of patients affected would probably be small, but the selective strategy reveals the financial pressures that Mayo is facing in part due to federal health reforms. For while the Affordable Care Act has reduced the number of uninsured patients, it has increased the share covered by Medicaid, which pays around 50 to 85 cents on the dollar of the actual cost of medical care.
Mayo will always take patients, regardless of payer source, when it has medical expertise that they can’t find elsewhere, said Dr. John Noseworthy, Mayo’s CEO. But when two patients are referred with equivalent conditions, he said the health system should “prioritize” those with private insurance.
More than 300,000 Minnesotans have gained coverage in the last three years from Medicaid and the related MinnesotaCare program for low-income households, a result of federal health reforms under the ACA and shifts in the U.S. economy. That means hospitals now get paid for patients who might previously have received charity care — but at Medicaid’s mandated rates.
In his speech, Noseworthy said a recent 3.7 percent surge in Medicaid patients was a “tipping point” for Mayo.
“If we don’t grow the commercially insured patients, we won’t have income at the end of the year to pay our staff, pay the pensions, and so on,” he said, “so we’re looking for a really mild or modest change of a couple percentage points to shift that balance.”
Mayo reported a sharp increase in the amount of unreimbursed costs related to Medicaid patients, from $321 million in 2012 to $548 million in 2016. The figures include its campuses in Arizona and Florida. Mayo nonetheless remained profitable in 2016, with income of $475 million.
The accompanying photo shows “Mayo Clinic CEO John Noseworthy, right, left a meeting with President-elect Donald Trump, his transition team and Johns Hopkins Medicine CEO Dr. Paul Rothman, left, in December in Florida.” That would be the now president who is siding with the Republican effort to kick 24 million people off of health insurance.
So what should we do?
The case for universal health care
The GOP is fond of spreading fake news about how awful is the health care in other developed countries. However, the truth is far different. What is true of American health care, then, now, and in the GOP’s version of the future is that we are all subject to The Fake Freedom of American Health Care. Here are snippets from the New York Times op-ed by a now American citizen who, originally from Finland, is quite familiar with health care Scandinavian countries. The simple fact is that our spending more does not get us better outcomes than those in other countries. Here are essential snippets.
Eight years ago I moved to the United States from Finland, which like all the Nordic nations is a wealthy capitalist economy, despite the stereotypes you may have heard. And like all those countries, Finland has invested in a universal, taxpayer-funded and publicly managed health care system. Finns constantly debate the shortcomings of their system and are working to improve it, but in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes — which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City — and if I needed to see a doctor, I had several options.
For minor medical matters, I could visit a private physician who was provided as a perk by my employer. Or I could call the public clinic closest to my home. If I saw the private doctor, my employer picked up the tab, with the help of public subsidies. If I went to the public clinic, it might cost me a small co-payment, usually around $20. Had I been pregnant, most care would have been free.
If I had wanted to, I also could have easily paid to see a private doctor on my own, again with the help of public subsidies. All of this works without anyone ever having to sign up for or buy health insurance unless he wants additional coverage. I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.
Republicans are fond of criticizing this sort of European-style health care. President Trump has called Canada’s national health care system “catastrophic.” On CNN recently, Senator Ted Cruz gave multiple examples of how patients in countries with universal, government-managed health care get less care than Americans.
In Europe, he said, elderly people facing life-threatening diseases are often placed in palliative care and essentially told it’s their time to go. According to the Republican orthodoxy, government always takes away not only people’s freedom to choose their doctor, but also their doctor’s ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.
But are Republicans right about this? Practically every wealthy capitalist democracy in the world has decided that some form of government-managed universal health care is the most sensible and effective option. According to the latest report of the O.E.C.D. — an organization of mostly wealthy nations — the United States as a whole does not actually outshine other countries in the quality of care.
I’m skipping the outcomes cited that show that American health care is not #1, among them survival rates following some diseases, for example, breast, cervical, and colorectal cancers. You should read the op-ed for the rest of the evidence.
What passes for an American health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven’t even been seriously sick or injured yet.
As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.
So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.
Here is my appeal to Republicans: If you really want to free Americans and unburden American employers, why not try, or at least seriously consider, some form of government-managed health care, like almost every other capitalist democracy? There are many ways of giving people choice and excellent care under government management. Universal publicly managed health coverage would even free America’s corporations and businesses to streamline their operations, releasing them from bureaucratic obligations that to me, coming from Finland, I have to say look weirdly socialist. …
In wealthy capitalist democracies all around the world the government itself also has an essential kind of freedom. It’s a freedom that enables the government to do work on behalf of the citizens who elect it, including negotiating the prices of health care with providers and pharmaceutical companies — a policy that has led to lower drug prices in those countries.
But here is the thing. As long as Republicans believe that health care is a commodity, subject to the so-called “free market”, then all they have to offer America is the fake freedom of health care for profit.
The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power. It is not like buying a consumer product, where choosing not to buy will not endanger one’s life. It’s also not like buying some other service tailored to individual demands, because for the most part we can’t predict our future health care needs.
So I return to my headline question. Given that we can manage health care better - as the Nordic countries do - why would any doctor be a Republican?