A Single Payer Cautionary

I was meeting with colleagues around the nation last week  and in one of our small group sessions we were mulling over strategies for moving legislatures toward adopting universal access to health care. My counterpart from a neighboring state raised the issue of the singlemindedness of the single payer advocates he deals with. Any willingness to discuss alternatives is, according to them, betrayal. 

I am wary of singlemindedness toward any solution to public problems in what some theologians call  — aptly in the case of public policy — a “fallen creation.” The attitude of the single payer purists reminds me of the old joke about the revolutionary exhorting the crowd: “Come the revolution, all will be peaches and cream!” A voice from the audience calls out: “But I don’t like peaches and cream.” The revolutonary replies: “Come the revolution, you will have to like peaches and cream!”

I pointed out that if a single payer system worked like Medicaid, the whole system would crash. Group demurrals. So I qualified my comment: “That is, the Medicaid system in New York.” Case in point:

A new report shows that while New York’s Medicaid program is one of the richest for patients in the country, it’s second to last when it comes to the amount it pays doctors and other health care providers. Only New Jersey ranked lower.

That can be bad news not just for doctors who treat Medicaid patients, but for patients who may find limited Medicaid-paid care, especially in rural areas…

While New York has generously spent more per Medicaid enrollee — $7,500 — than nearly every other state, it performed poorly when evaluated for payments to health care providers, according to the report by Public Citizen, a nonprofit interest group.*

For example… Blue Cross Blue Shield reimburses $2,979 for a PET scan — which is similar to an X-ray — while Medicaid pays $1,970. For a CT scan of the sinus, Blue Cross Blue Shield reimburses $275, while Medicaid pays $120. A CT scan is a method of making multiple X-ray images and using a computer to construct cross-sectional views from those images.

“Come the revolution, a CT scan will always be $120?” That’s why health providers have been wary of single payer health insurance all along. If advocates do not take this problem seriously, in my opinion they are simply posing for the cameras.

And it won’t do simply to dismiss doctors and hospitals as “greedy.” When my children were young, we took them to a pediatrician who accepted Medicaid. He was one of a small handful in his county who did, and he did so with a sense of mission. He also lived in a modest country home. He owned two goats, which he kept for milk.  I always admired his public spirit and his lifestyle of volutary simplicity, but I believe it unfair to expect an entire profession (yea, even the clergy!) to have simplicity foisted upon them.

The Spitzer administration proposed on Thursday an increase in the Medicaid reimbursements paid to doctors in the 2008-2009 budget. The goal is to make it more financially attractive for more doctors to accept Medicaid patients. The proposal is going to the Legislature.

More details soon. Until Medicaid reaches parity with market reimbursement rates, and includes mechanisms to prevent those rates from slipping into levels of absurdity such as, say, New York’s public assistance grants have, I believe that single payer remains a loser.

(see Public Citizen Report here)

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