Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis

A politician says -- I support health care for all.

That is a politician you should support, right?

Wrong.

A politician says -- I support universal health care.

That is a politician you should support, right?

Wrong.

Universal health care.

Health care for all.

More often than not, these are code words for -- keep the private insurance companies in the game.

The only way we are going to dramatically improve the health care system is to get the private insurance companies out of the game.

That means replacing the hundreds of private insurance companies with one payer.

One nation.

One payer.

Single payer.

Single payer already exists for Americans over 65.

It's called Medicare.

Why not single payer for everyone else?

Because the insurance companies don't want it.

And they have a lot of money and political influence.

Last week, Tom Daschle was forced to pull out as Obama's nominee for Secretary of Health and Human Resources because he failed to pay taxes on a limousine and chauffeur.

Or as one DC insider summed up Daschle's problem -- "he's a limousine liberal who didn't pay taxes on his limousine."

But what was widely overlooked in the flood of news last week?

Daschle's close ties to the health insurance industry.

The fact that he gave speeches to the industry's key lobbying group -- America's Health Insurance Plans (AHIP) -- at $20,000 a pop.

AHIP has one litmus test -- you must oppose single payer at all cost.

If you oppose single payer, you are with the insurance industry.

If you favor single payer, you are against the insurance industry.

Daschle opposed single payer.

He was with the insurance industry.

And against the interests of the American people.

Just go down the list of health advocates and advocacy groups -- and apply
this test.

Ron Pollack and Families USA -- opposed to single payer now.

Physicians for a National Health Program -- for single payer now.

SEIU -- opposed to single payer now.

California Nurses -- for single payer now.

Health Care for American Now -- opposed to single payer now.

Public Citizen -- for single payer now.

AARP -- opposed to single payer now.

And if you dig deep enough, you will find that that most people and groups who are opposed to single payer have ties to the health insurance industry.

I decided to test out my thesis with the case of Atul Gawande.

Gawande is the Boston surgeon and New Yorker writer.

And he's being pushed by Pollack and others as a replacement for Daschle at HHS.

In his most recent article in the January 26 New Yorker titled Getting There From Here: How Should Obama Reform Health Care? Gawande argues against single payer now.

I started looking to find out whether Gawande had ties to the insurance industry.

And sure enough, there it was.

Gawande is scheduled to give the keynote speech to AHIP's annual public policy conference on March 11 in Washington, D.C.

So, I shoot off an e-mail to the New Yorker and to Gawande and ask - is Gawande being paid by the health insurance industry for this speech?

And how much has he been paid by the insurance industry for speeches in the past?

And why weren't New Yorker readers informed of his ties to the industry?

Alexa Cassanos from the New Yorker writes back first.

"Atul Gawande does not accept speaking fees from pharmaceutical or medical-device companies, and speaking payments from insurers or insurance lobbyists are relayed directly to charity," Cassanos says.
Okay, a follow-up.

Why does he take money from the insurance industry but not from the pharmaceutical or medical device companies?

And how much has he taken from the insurance industry?

On the phone, Cassanos says "there's no story here," but that she will try and track down the information.

I next hear from Dr. Gawande, via e-mail, who points me to a just updated (February 6, 2009) conflicts of interest disclosure statement on his web page.

In it, Gawande says: "I don't benefit financially from speaking to for-profit medical businesses (whether they are drug companies, device
companies, or insurance companies) -- either I'm not paid or I arrange for the fee to be donated to charity (including my family's church, our WHO work in patient safety, and a rural college my father started in India)."

I write back to Dr. Gawande.

I again ask him why he says he will not take money from medical device and pharma companies, but will take money (for his charities) from health insurance companies.

This time, he clarifies what Cassanos from the New Yorker said.

"The reason I haven't received money from for-profit drug or device manufacturers is that neither have asked me to lecture," Gawande says. "If either did and I accepted, I would donate the fee to charity or not accept the fee."

As for his insurance industry ties, Gawande writes:

"Since I decided in April, 2007, to write on health reform policy - I spoke to AHIP once (and the fee I received was donated to charity), I've scheduled to speak to AHIP again in March (that fee will be donated to charity), and I've not lectured to any for-profit insurers."

AHIP is of course the lobbying group (technically a non-profit) of the for-profit insurance industry.

"I would have received $31,500 in 2008 after the speaking agency's 30% fee was taken, and $28,000 in 2009," Gawande writes.

"I chose the charities independently and AHIP is not informed whom they are," Gawande says. "The charities are the Trinity Church, Boston, the Student Education Support Association which provides for students attending a nonprofit college my father started in rural India, and the Brigham and Women's Hospital Foundation for our work with the WHO to reduce unsafe care globally -- I am not permitted to benefit financially from these funds."

Gawande does not reveal what he was paid by the insurance industry prior to April 2007.

He has been speaking to AHIP groups around the country since at least 2004, according to the AHIP web site.

But more importantly, don't his New Yorker readers deserve to be told that his favorite charities -- including his church, a non-profit set up by his father, and a foundation affiliated with the hospital where he works -- are benefiting financially - and by how much -- when he speaks to the private health insurance industry ?

As for his opposition to single payer, he remains steadfast.

In a q/a with New Yorker readers last week, Gawande defended his opposition to single payer now.

"Replacing the entire health-financing system with Medicare would require most working-age people to leave their current insurance plans," Gawande writes. "It would change the finances of every hospital and doctor in the country overnight. It would require replacing the premiums we pay with a tax, with massive numbers of both losers and winners. It seems simple in theory, but in practice it never is. This would be a whole new path for health care. No country has swept away their health system and simply replaced it like that. As I said in the article, one would have to be prepared for an overnight change in the way people get 3.5 billion prescriptions, 900 million office visits, 60 million operations - because how these are paid for is critical to whether and how they are provided. Doing away with private insurance coverage is no less sweeping than saying we'll do away with public insurance programs or do away with employer-paid health care. No major country has simply swept away the way so many people's care is paid for. And the reason is that people have legitimate fears about what will happen to them."

Dr. David Himmelstein, a founder of Physicians for a National Health Program, calls this argument "bogus."

"Patients do not care what their insurance plan is - just that it pays for the care they need. A transition from a system where virtually everyone has only partial coverage to one where they have full coverage is not a disruption for patients," Himmelstein said when we asked him to respond to Gawande. "Several nations have made abrupt changes in the financing of care. The UK instituted the National Health Service - eliminating insurance and private payment for care at a stroke. Each Canadian province went from a private insurance system very like ours to its current system virtually overnight -- though not all provinces underwent the change simultaneously. Taiwan changed to a single payer system about 10 years ago at a stroke."

"Medicare replaced private coverage for the elderly -- who account for about 30% of all hospital patients -- about nine months after its passage. That occurred in an era before computers. The entire task of enrolling tens of millions of patients, inspecting virtually every hospital in the nation -- to certify that they were desegregated, which was mandated by the Medicare law -- and set up a new payment apparatus was carried out using paper records. Why is a shift of the other two-thirds of our system more difficult?"

"The new payment system would be far simpler than the current one -- hospitals would receive a global budget, which initially would be based largely on their previous year's revenues. Medicare currently collects all of the financial info needed to do such budgeting at the outset. Per-patient billing for hospital care would be eliminated. For doctors, Medicare already has a fee schedule, which should be modified somewhat, but already serves as the benchmark for most private plans. Expanding this payment system to cover all fee-for-service billings would be trivial. Paying for drugs is similarly pretty simple and straightforward, with most of the needed infrastructure already in place."

"In sum, his arguments are bogus unless you assume that we are far less competent than people in other nations, and than we used to be," Himmelstein said.

Gawande will travel to Washington on March 11 to speak to AHIP.

The title of his speech -- Fixing Health Care from the Inside Out: The Physician's Role in Health Care Reform.

The majority of physicians in the United States now support a single payer system.

Dr. Gawande does not and is coddling the private health insurance industry.

When Daschle was driven out of office last week, a DC insider made the following observation:

When people first come to Washington, they see it as a putrid swamp that breeds corruption.

But after they stay awhile, they begin to see it as a hot tub.

Et tu, Atul?