Jodi Hilton for The New York Times Dr. Marcia Angell, a senior lecturer at Harvard University and former editor of The New England Journal of Medicine, in her office in January.Dr. Marcia Angell is a senior lecturer in social medicine at Harvard Medical School and former editor of The New England Journal of Medicine. A longtime critic of the pharmaceutical industry, she has called for an end to market-driven delivery of health care in the United States. She spoke with freelance writer Anne Underwood.
President Obama hopes to increase the number of Americans with insurance and to rein in costs. Do you believe any of the plans under consideration by Congress will accomplish those goals?
They won’t, and that’s the essential problem. If you keep health care in the hands of for-profit companies, you can do one or the other — increase coverage by putting more money into the system, or control costs by decreasing coverage. But you cannot do both unless you change the basic structure of the system.
Segments of the health care industry — pharmaceutical companies, for instance — are promising to cut costs.
It’s not going to happen. These are investor-owned companies. Their fiduciary responsibility is to maximize profits. If they behaved like charities, heads would roll in the executive suites.
But what about market mechanisms for reducing costs? Wouldn’t the public option, for instance, provide competition for the insurance companies?
“I’m afraid the president squandered a good opportunity.”
Theoretically it would, but I doubt the public plan will pass. Industry is lobbying against it, and the president has not said this is a “must.” Even if it does pass, I’m afraid the private insurance industry will use their clout in Congress — and they have enormous clout in Congress — to hobble the public option and use it as a dumping ground for the sickest while they cream off the young and healthy for themselves.
How? Won’t insurance companies have to cover all applicants regardless of health status?
It’s hard to regulate an enormous industry without setting up a bureaucracy to oversee it. That’s very expensive and creates a whole new set of problems.
How about the individual mandate? Wouldn’t it reduce costs per capita by bringing in young, healthy people who are currently uninsured?
No. In Massachusetts [which enacted an individual mandate in 2006], there is no real price regulation. Essentially what the mandate does is say to people, you will go into this treacherous market and buy insurance at whatever price the companies choose to charge. In effect, it’s delivering a captive market to these profit-oriented companies.
Are people at least getting better health care in Massachusetts now?
Massachusetts already spends one-third more on health care than other states, and costs are rising at unsustainable rates. As a result, they’re chipping away at benefits, dropping beneficiaries and increasing premiums and co-payments.
Then what’s the path to meaningful cost control?
The only way to both control costs and have universal comprehensive coverage is a single-payer system — a nonprofit, single-payer system. Nothing else will work. All other advanced countries have some form of a single-payer system, and they pay less than half as much per person as we do. We should be asking, why is that so? It’s not because we provide more basic services. We do provide more tests and procedures for those who can pay, but not more basic services — and we don’t cover everybody. So why is it so? We are the only advanced country that delivers health care in a system that’s set up to generate profits, not to provide care.
If a single-payer system isn’t feasible politically, aren’t the current proposals at least better than doing nothing? Isn’t half an aspirin better than none?
I think not. As costs continue to soar, people will not say, “That didn’t work. Let’s try a single-payer system.” Instead, they’ll try to pay for the costs in piecemeal ways, by increasing co-pays and deductibles, by limiting services, by making the system less equitable and less comprehensive. I’m afraid the lesson they’ll draw is that universal care is impossible.
But I’m not convinced that getting a single-payer system now is politically infeasible. The public would be happy with Medicare for all. Polls have shown that the public loves Medicare. The problem isn’t the public. It’s Congress, which caves in to special interests.
If Congress is reluctant to cut out the insurance companies, is that partly because they, like the major banks, are too big to fail?
A nonprofit, single-payer system would lead to job losses in this sector, which constitutes 17 percent of the economy. But what about the other 83 percent of the economy? They’re being bled to death. Businesses can’t compete globally because the cost of providing coverage to their workers is so exorbitant. Whatever loss of jobs you might see would be more than offset by benefits and job gains in the rest of the economy.
[As for the insurance companies,] you could introduce the program incrementally. You could do it state by state. Or probably better, you could do it decade by decade. Medicare kicks in at age 65. In the first stage, you could take it down to 55. Between 55 and 65, people are vulnerable. They’re losing jobs, losing health care. They’re starting to have more medical needs. After a few years, you could drop it to 45, then 35. It would give insurance companies time to adjust.
But Medicare is already hugely expensive. How can we afford such a plan for everyone?
Medicare costs are rising at an unsustainable rate because care is provided in a profit-maximizing system. The prescription drug benefit was nothing but a bonanza for the pharmaceutical industry. I would change that. I would also adjust the fee schedule, which preferentially rewards highly paid specialists for very expensive tests and procedures. For the system to work, it would have to be a nonprofit delivery system.
How much could we save in administrative costs?
On average, the private insurance industry takes 15 to 20 percent right off the top of the premium dollar for its administrative costs and profits. That’s a lot to siphon off by an industry that adds almost nothing of value. It’s just a middleman. Medicare has overhead costs of less than 3 percent.
With the money in the system right now, we could cover everyone for every medically necessary service. But the system has to be distributed according to medical need and not as it currently is — as a commodity. Today, those who can pay get lots of M.R.I.’s they don’t need, while those who are uninsured can go without ones they do need.
Military historians say we’re always fighting the last war. Is Mr. Obama now fighting the last health care war, in which Congress rejected the Clinton plan partly because it was developed without consulting other interested parties?
Yes. Mr. Obama has decided that he will listen to everybody. But it’s not working for him, because the public can’t become enthusiastic about a plan that doesn’t exist. That’s what he’s asking. Now Congress has gone home, and for the next month the special interests will be out there scaring people with stories of rationing and socialized medicine.
Is the president really bringing everyone to the table?
He’s bringing everyone to the table except the single-payer people. It’s very odd. When he was a state senator, he emphatically favored a single-payer system. And in his July 22 press conference on health care, he stated that the only way to provide universal health care is with a single-payer system. Then he moved right on, as if that was somehow self-evidently absurd.
So are you opposing this reform?
I am, though not for the same reasons as the Republicans and Blue Dogs. I’m opposing it more in sorrow than in anger. I’m afraid the president squandered a good opportunity.
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From 1 to 25 of 113 Comments
Right on. Everything stated is obvious. From someone raised in the first country with universal healthcare and who has practiced medicine here. The most awkward step will be the redistribution of physician payment away from the procedures to the generalists (of whom there are too few).
— mike WIlsonMike W.
Single payer would be a vast improvement over our current system which simply allows health insurers to extract a share of tribute from most health care finance.
Single payer will not ultimately allow us to ignore our current primitive system of medical care delivery. See below for an immodest proposal:
http://wonksanonymous.com/2009/05/11/wonks-anonymous-goes-forthe-x-prize-for-health-care-reform.aspx
— Wonks AnonymousRedistribution of payment ! Sounds like redistribution of wealth. A bad socialist idea. Generalist training is 3 years post med school. Evil invasive cardiologists train those same three years PLUS 4 more. They routinely awaken in the middle of the night to perform urgent angioplasty – saving lives. They wear lead aprons in attempt to shield radiation but cancer risks are higher and significant orthopedic problems are prevalent. More than twice the training and multiple more times the risk. ??For near equal pay?!!
Americans should not lose sight of the training required to become a “specialist”. The concept of redistribution of income regardless of training and experience can be applied to other professsions as well.
— Doci agree with her but also recognize that it would be near impossible to jamm this through. right now the for profit special interests are NOT fighting this tooth and nail. pharma is takingouot pro reform ads. insurence is not advertising.
but her point that its the for-profit elements in the delivery system ring true.
maybe this needs to be done in 2 steps to bring everyone along?
as an aside i have read that onje of the proposals does contemplate cutting fees to specialists and rising them for GP’s.
— jonThank you for this wise and well-worded interview, Dr. Angell.
And NYTimes, please post this more prominently. All your readers should have a chance to see this!
— MiraThe question is no longer “Will we get Single Payer Health Care?” rather it is “WHEN will we get Single Payer Healthcare?”
With this in mind remember no matter how bleak the situation may appear at this time every action we take in favor of Single Payer Payer raises consciousness. Break throughs come at odd times from strange places being prepared to exploit those break throughs is crucial.
— Bob Marston“The problem isn’t the public. It’s Congress, which caves in to special interests.”
This is so right, as is the comment that the “fiduciary responsibility [of investor-owned companies] is to maximize profits.”
Unfortunately, the only way for insurance companies to maximize profits goes against the national interest.
Did you know that 65% of conservative U.S. medical students agree that access to health care is a fundamental human right?
Frank, Carrera, Dharamsi, Political Self-characterization of U.S. Medical Students, 2007 http://tinyurl.com/m97eer
Of course, there is a great deal of stupid protests. After all, in the Obama “landside” millions of people voted for the worst president in American history. They were noisy during the election and they are noisy now. The problem is that President Obama trusted the interests and not the people.
Obama supported single payer in the past because it is the best way to go. He is against it as president because he thought a “public option” would more easily pass. He should have stuck with single payer.
LeoTheLess” on Twitter
— Leo WongThank you Dr. Angell for such an eloquent, truthful synopsis of the unraveling of the health care change plan. I applaud you for your honesty and I too am saddened by this lost opportunity.
— sharon van hornI should have written “voted for the party of the worst president of American history.”
LeoTheLess on Twitter
— Leo WongDr. Angell likes to point to pharma and med tech companies as the root cause of out of control medical costs, but pharma is less than 10% and med tech less than 4% of the costs of healthcare. (source: PHRMA Annual Report)
Rather, physicians and hospital costs are 52% of the costs of healthcare. Atul Gawande’s recent New Yorker article entitled “The Cost Conundrum” and this recent healthcare venture presentation (http://www.slideshare.net/MedicalVentures/tie-healthcare-technology-innovation-zen-chu) highlight the more significant cost management areas lie in health reform – paying doctors for each procedure and the incentives that creates.
Health cost reform will not move the needle unless physician pay for procedure and hospital episode-based payments reign in these largest segments.
— HealthGeekMore people need to see this.
We must remove “shareholders” from the healthcare system. Patients and providers should be more important then shareholders.
How much “profit” do the large publicly traded corporations pull out of our healthcare system to please shareholders?
Cover patients, pay providers, eliminate shareholders!
— WillA single payer system makes the most sense but all interest groups will make certain it will not happen. I don’t know how we will be able to balance cost, efficiency, and quality of care in the same spectrum.
— Pam SudbanthadIf you would like to help pressure Congress to pass single payer health care please join our voting bloc at:
— Fredhttp://www.votingbloc.org/Health_Bloc.php
Dr. Angell nails it head on. This country should at least be on a path to single-payer healthcare. However, I fear that regardless of the current reform efforts (which will likely fail) it is going to take a major catastrophe to make this happen. We live in a country that views a basic necessity as a hugely profitable enterprise. Until we change this mindset nothing will change…
— Dave“Doc”
Cardiologists, and especially the increasing numbers who sub specialize, should only be seeing a specific population of tertiary care heart patients who truly benefit from their expertise.
In cases where all that extra training and time are genuinely needed cardiologists, or any specialists, are and will continue to be consulted.
But where the extra training is not necessary it is a waste of the specialists time and a waste of the public’s money.
— micheleWhy doesn’t someone start a website profiling the greedy health insurance executives. Why do they get to hide behind their lobbyists? This country is truly broken if we cannot pass a useful plan (single-payer being useful and the public option being a compromise on useful). If the public option is killed, Obama will lose the support of progressives, which will take the wind out of his sails. He will have failed in my mind.
— DavidThis is a wonderful interview. Thank you very much for your your opinions, Dr. Angell! As #5 Mira says, the NYT should give it much more prominence. At the very least, it should give a link on page 1 to this interview. The NYT should also do an interview on single-payer with Dr. Scheiner, who was Obama’s personal physician.
The town meeting debacle has shown well that, as Dr. Angell says, most Americans are completely in the dark about what single-payer is and how actual single-payer systems work around the world. The NYT has also been surprisingly lax about providing readers with information on the various health care coverage systems in other large capitalist democracies, a lack which has added to the general confusion in 2009. To remedy this, the NYT should run a supplement or a major series of articles in the next month about how other economically advanced countries deal with health care coverage. Many of them use a mix of single-payer coverage and regulated private health care that could serve as models for the US. The Times should put a spotlight on Japan, Germany, France, South Korea, and other capitalist economies that are controlling costs and providing quality care using various forms of single-payer. If Times readers had a handy mini-handbook of world systems to refer to, they could make comparisons with the current health care reform proposals, and the debate would become more intelligent, realistic, and future-oriented.
— C.C.Does anybody have the statistics on what state law says about how much of the premiums need to be paid back as medical benefits? I heard from a reliable source that it’s only 55-60%.
How much of our premiums are used for lobbying costs?
How much are used for stockholder dividends?
How much are used for denial of benefits bureaucracy?
How much are used for marketing?
How much are used for executive compensation?
How much are used for actuarial decision making?
— Johnny EI think we need improvements in critical thinking & education more then anything else in this nation.
— joeyjoey
Dr. Angell hits the nail on the head when she states that a single payer system of some sort (shared by other countries that have successful medical systems) is the only solution to cost control.
I live in Japan where I recently suffered a bike accident and ended up in the hospital for a month and a half. Total cost of care? $11,000. During that stay, I asked some of the physicians about their jobs and Japan’s social insurance system (a universal one). They said that although they weren’t paid as much as they might be if they worked abroad, they felt the system adequately covered the needs of society in providing healthcare to all entitled to it and said they liked their jobs. Japan’s system has some quirks and is not perfect (it’s subject to increased costs as well and is by far more conservative than that of the U.S.), but what it is is low cost and available to all for a low cost, which compared to the U.S. is a completely foreign concept.
In the current debate, one must question whether the ultimate goal is profit for healthcare companies and providers or the provision of healthcare for the good of the whole, not unlike the provision of roads, which everyone seems to share and benefit from without much complaint despite their tax dollars being used to fund them.
— NickDr. Angell has claimed that ” All other advanced countries have some form of a single-payer system.” Isn’t this wildly inaccurate?
What about Australia, France, Germany and the Netherlands — all of which achieve universal coverage through a mix of public and private insurance?
It seems our entire conversation in the U.S. is focused on the Canadian and British models. Why is that? If I were our Health Tsar, I’d be moving us towards the Netherlands model:
http://en.wikipedia.org/wiki/Health_in_the_Netherlands
— JSThose who argue that an incremental step toward a single-payer system – of offering a public option – is better than nothing misses the reality that special interests (with the help of the Obama administration and Congree) will throw all their might to make sure the public option fail (e.g., by pushing high risk/users to it) and use it as an example to dismiss any future consideration of a single-payer system. As Dr. Angell insightfully points out the core of the current problem lies in the profit incentive which is incompatible with the objectives of affordable, quality healthcare for all Americans.
— LeeI agree with Dr. Angell.
I do not understand why we cannot learn how the medical care system works at less cost elsewhere. Of course, you have to want to know such things and be ready to learn.
No matter how the current fracas turns out, I doubt anyone will be willing to approach the subject again for another generation.
— Walter L BattagliaWhat a well thought out position. And from someone with a lot of gravitas in this area.
I agree with Mira’s comment, the Times should run her arguments in a place with more exposure-a front page interview or an Op-Ed piece.
— Mike Adamowiczthis bill so bad the designers have rejected
— unscrutinizedit for themselves and the ones they love the most.
ANY QUESTIONS?