We want health care "PLANS," not actual health care, I guess.

"Obamacare is a radical expansion of the status quo." —JD Kleinke

    

Sept 2012

December 2025

When SCOTUS initially upheld the constitutionality of "Obamacare" (the PPACA), lyrics to a song promptly fell right outa my head in about 10 minutes. Two days later I posted a goofy YouTube music video.

 

BTW: Noted medical economist / novelist JD Kleinke is my friend (fellow guitar cat). He once told me "an economist is someone who sees something that works in practice and tries to determine whether it'll work in theory." 

 

OK, BACK UP TO 1994

 

My first grad school paper. An "argument analysis & evaluation" assessment of the "Single Payer" proposal published in JAMA.

UNLV EPS 701 Fall 1994, Argument Analysis Paper (pdf)

A Better Quality Alternative:
Single-Payer National Health System Reform

Gordon D. Schiff, MD, Andrew M. Bindman, MD, Troyen A. Brennan, MD, JD, MPH; 

Physicians for a National Health Program Quality of Care Working Group.
JAMA, September 14, 1994—VoL 272, No. 10

Argument synopsis:
Notwithstanding public misgivings about making significant public policy driven changes in the U.S. health care industry, there is extensive and persuasive empirical evidence of costly inadequacies in the system—such as lack of access/coverage, uneven levels of quality of service and outcomes, market-driven rather clinical priorities, waste and duplication, etc.—that can best be corrected by a unified approach to improvement driven by a scientific focus on quality issues (broadly defined) rather than those of short-term cost-control, competition, and piecemeal regulatory strategies and tactics. A single-payer health care system reformed by implementation of the ten principles detailed herein would at once extend medical access to all, reduce costs, improve clinical outcomes of the sick and injured, and elevate the overall health status of the nation, resulting in win-win consequences for providers and citizens alike.

I first flowcharted every declarative sentence / sub-clause "truth claim" sequentially to get at what the authors were precisely advocating ("seek first to understand'). Only after that would I go on to "evaluation" ("seek then to be understood")—basically making my argument going to the cogency of the proffer. (Basically, think "ASSUMING - BECAUSE - DESPITE - THEREFORE - ELSE" logic and concomitant evidence)

 

I had at least 100 hours in that paper. Great fun. Notwithstanding a 2nd grad course in "History of Ethics" (11 required textbooks) and my day gig at the Nevada Medicare Peer Review.
 

I'm revisiting my conclusions (to wit, pg 54).

Overall Evaluation:
The following alternative courses of action are generally advanced in the health care debate:

1. Status quo: the system works fine, and normal incremental quality improvements at the provider level will suffice. Get a job.
2. Insurance reform: prohibit exclusion and enforce community rating to reduce the insurance premium stratification characteristic of the present system.
3. Expand existing public payer programs such as Medicare to cover the working poor and otherwise uninsurable.
4. Capitated managed competition, with "employer mandates" to provide choices in beneficiary alliances for pooled coverage bry*g power, administered though the workplace.
5. Tax inducement programs such as the "Medi-save" approach in which workers use pre-tax dollars to purchase catastrophic coverage and pay for routine health expenses themselves.
6. The public single-payer system based more or less on the Canadian model.

No one can dispute that the health care industry can be improved. Any system an be improved. Problems such as lack of access, arbitrary and often wildly excessive pricing, inexplicable variations in clinical practice and outcomes are well-documented and cry out for solution. That tends to rule out option 1. The question is one of extent: has the case been made that the health care industry requires comprehensive national reform?

In sum, the authors' argument has many strengths, particularly in their exhaustively documented enumeration of the shortcomings of our present health care system—to the extent to which it can be characterized as a "system." There is, however, a plausible alternative to a public national single payer system that would meet many of the goals sought by these advocates, and it is not a theoretical one. Utah's IHC (Intermountain Health Care) organization is a private, vertically-integrated health care corporation serving Utah and western Wyoming residents. It is a large for-profit network of hospitals, clinics, physicians, and related operations such as home health services. IHC is essentially a managed-care system with subscribers who pay set fees and minimal co-payments. Unlike other HMO-type operations in the state that typically experience subscriber turnover rates of approximately 15% per year, IHC’s turnover rate is less than 0.5% (that's 0.005), at competitive prices. They accomplish this by an organization-wide, enthusiastic, almost religious commitment to the very CQI principles outlined above. IHC quality improvement programs are directed byDr.  Brent James, a surgeon and nationally respected leader in health care CQI education. Having myself undergone their health care CQI training course over the period of the past six months as a part of my work, I can attest that IHC, while not yet perfect, effectively applies nearly all of the recommendations cited in this article, albeit on a smaller scale (and that may indeed be a significant virtue). They  are in essence a microcosmic single-payer system, but one successful in the private sector, driven not by publicly imposed mandates, but by their own thorough knowledge of and dedication to CQL IT is difficult to see at this point whether the asserted advantages of a national public system would add net value beyond the type of operation that IHC represents.

To be fair, IHC operating in a fairly prosperous, culturally homogeneous region enjoying a great deal of social and political unity. Here in Nevada, by contrast, though we share a common border and similar population size and geography with Utah, the social milieu could not be more different. IHC might not encounter the same level of success in other regions, and their successes do not impact those who cannot obtain coverage-and a central issue of this article has been about the significant negative impact of such a deficit. The IHC example does, however, stand in stark relief to both the inadequate business-as-usual attitude, and the proposition advanced above that a national single-payer system is the best path to effective health care reform. other examples exist around the nation also; one that comes to mind is Northwest Hospital in Seattle whose presentation at the Annual Quality Congress of the American Society for Quality Control this year revealed yet another organization deriving significant cost savings and quality improvement from diligent application of CQI methods. 

Rule Number One of CQI is "listen to the customer," and thus far the customers are prohibitively wary of the idea of creating a huge new national program, a political reality that is unlikely to shift anytime soon. The argument presented by Schiff et al takes into account an enormous amount of evidence and theory generated from within health care and the wider quality sciences, but serious questions remain unresolved with respect to the needs and concerns of health care consumers, whose overwhelming support would be needed to implement a single-payer health care system. 

I've been gumshoeing this topic for a long time. e.g., see "Public Optional." "Shards of Health Care" anyone?

 

Stay tuned...