What About The Alligators?

A little over twenty years ago, I was working at a good-sized healthcare organization.  Three hospitals, 20 clinics, spread over a 10 county area.  Most of the facilities were in small rural towns, and as you can imagine, there was a lot of travel involved.  That was when the organization decided to jump into some new technologies, which were touted as the future, which were going to revolutionize healthcare delivery and patient care.  They were telemedicine and the electronic medical record.   It would solve so many problems that the organization faced.  No more having patients drive long distances to consult with a specialist, it could be done right there in their local clinic!  No more waiting for records to be sent around, no more digging through reams of paper records on a patient, lab results available quickly, and oh, the opportunity to do outcome-based research to determine what worked in treatments!  It was a great shining promise.  Money was set aside, grant money was obtained, and we set about getting it done.  That was the beginning of our problems.

In the “ideal,” it sounded like a great thing, and “not that hard” to implement.  All we had to do was to connect all the various clinical systems into a new EMR system.  For telemedicine, well, we had to obtain the videoconferencing equipment, and get that set up in all the clinics and at the hospitals.  Sounds simple?  Yes, on paper and in the presentations.  In reality, it turned into a  nightmare.  Clinical systems didn’t want to “talk” to each other.  Even when they supposedly “spoke” the same language, it turned out that they were often using a customized “dialect” of it.  Some had to just send data, others had to receive data, and some had to do both.  Hammering that out – we built an interface to translate – took a very long time.  A change in one system by someone could cause a cascading crash, so extensive meetings and testing had to be done before any changes were made.  That “simple idea” cost huge sums of money and took several years to get mostly into shape.  Telemedicine?  Another set of headaches.  In order to do adequate videoconferencing, you need high speed data lines.  Which didn’t exist in our area, so more money to get them, along with scaling back the plans for it.  Another big problem was getting someone to pay for those consultations.  It turned out that insurance companies, Medicare, and Medicaid didn’t regard a consultation via video as “a specialist’s consultation” which they should pay for.   What was supposed to be a “revolutionary change” turned out to have many obstacles, be full of problems, far and away more expensive than anyone dreamed, and never lived up to the promise.

Over the past decade, I’ve had cause to think back to that experience a lot.   What makes me do that?  The litany about “Single Payer healthcare.”  It’s a liberal ideal, and it’s been around for a long time.  If you went to, or still do go to any of major liberal sites you’ll see endless talking about it.  One of the major conniption fits the liberal blogs had over the Affordable Care Act was that it didn’t institute “single payer.”  Now that Bernie Sanders has made it part of his campaign platform, they’re running wild over it again.  So, if it’s such a great thing, why do I seem to be rather … doubtful?  Quite simply, it’s the details, and that no one seems to be talking about the same thing.   Even then, there’s often a lack of understanding that universal healthcare coverage is not the same as single payer.   I don’t know how many times over the years I’ve heard this statement:  “All the other developed countries have single payer!”  Sounds good, right?  Except they don’t.  There are a number of them that have mandates, insurance exchanges, and other methods that give universal coverage, but they’re not “single payer.”

But it’s when you are discussing single payer, you find out that it’s more the concept of it they’re advocating, and not any specific system.  It often appears that they think it’s this standard method that all the countries with it use.  There’s really a huge amount of variability in how that works between countries,  and even in “single payer” systems in this country they like to point to as “examples.”  Let’s take the standard one, “Medicare for all!”  If nothing else, it shows they don’t understand Medicare.   Medicare is technically a single payer, but there’s also a need for supplemental insurance policies, as well as deductibles, co-pays, limits on coverage, and so on.  It turns out that some countries use a variation of that in their own single payer systems.  France, for example, where basic healthcare is covered under single payer, but supplemental insurance (which most buy) is used for things that aren’t.  If you look around the world, it turns out that every country that has “single payer” has significant variations.  Some countries have “everything by the state,” which means they own the healthcare facilities and the doctors are public employees.  Others have a mix of public and private providers, some systems are controlled by the central government, others by regional or “state” governments.  What is or is not covered varies as well, as does whether there are co-pays, private insurance, or some other payment plans.   How they pay for it also varies from country to country.

That’s why I have gotten into numerous arguments with various single payer advocates over the years, and even more now.  First, they confuse “universal” with “single payer.”  Second, they assume it’s “better” for this country than other means of reaching universal coverage, mostly “just because!”  Third, they can’t agree on what they mean by it, or point to a specific country that they want to use as a model.  Even if they do come up with one, it turns out that country’s model isn’t what they think it is.   Fourth, they don’t seem to have a clear idea of what will be limited under the plan.  Yes, there has to be limits, otherwise cost control is impossible.  Finally, they can’t detail a way to pay for this, and methods of ensuring that it won’t grow out of control.  Those are the basic highlights of why I get into these arguments, and it’s why I’ve been called every name in the book by various advocates.  I’m a “conservaDem,” a “Blue Dog,” a DINO, a “Republican in disguise” and more unprintable things.

As I stated in the opening section, I’ve been involved in another wonderful concept that turned out to be not so wonderful in trying to get it done.  There’s an old saying, “When you’re up to your ass in alligators, it’s difficult to remember that you are there to drain the swamp.”   Using that metaphor, I’ve found that the single payer advocates can’t tell you which of numerous swamps they want drained, can’t agree on the best swamp to drain, and deny that alligators exist.  Personally?  I’d like to know exactly which swamp you want drained.   Since I know alligators exist,  I want a realistic estimate of how many alligators there are in that swamp,  and a plan to deal with them before I start.  Otherwise, I’m not doing it.   I like the concept of single payer, and I  think it’s a nice goal.  But if you expect me to advocate your plan, you’d better be able to tell me about the alligators.   I’ve gotten too many tooth marks in the past to think it’ll be simple and easy.


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