A Physician Looks at the Health Care Struggle

— an interview with Susan Steigerwalt

DR. SUSAN STEIGERWALTis a nephrologist at Henry Ford Hospital in Detroit and an activist in Physicians for a National Health Program (PNHP). She was interviewed by David Finkel of the ATC editorial board.

Against the Current: What is PNHP, and why is there a group of physicians working for a single-payer system?

Susan Steigerwalt: PNHP has been around for about six years, with four to five thousand physicians and other health care providers as members. Most of us are involved because we believe that health care is a right, and that everyone has the right to the same level of care. We're all in the boat together.

Additionally, we believe that consumer should have a choice of who their doctors axe, not be assigned a physician without a choice in & huge Health Maintenance Organization. Many of us in fact are in HMOs, we aren't against them as such, but we think it's important to have consumer choice and flexibility.

Most important is getting the insurance companies out of the health care business. Over the past twenty years, four or five big payers (insurers) have emerged. We see twenty cents on the dollar of health care costs going for administrative costs, against eight cents in Canada. This results in the huge difference in health care costs, as a percentage of GNP, in the two countries.

Health care costs are rising in Canada, as they are here, but from a much lower base because they dropped way off when Canada adopted its single-payer system insurance around 1965. We know in addition that Canadians have a higher life expectancy and lower infant mortality than the United States, and that wasn't the case before they adopted the single-payer system so it's not, as some try to argue, that the there's some difference between the two populations.

In comparison to the single-payer proposal, “managed competition” (MC) will favor the largest insurance companies and wipe out smaller ones. Right now 48% of the commercial insurance market is still controlled by smaller companies, which will be forced out under MC. The effect will be corporate insurance monopoly, not competition.

We don't think in any case that health care should be an arena with people competing to provide and receive the cheapest treatment.

Our major concerns with MC are: (1) It isn't universal health service, it won't cover uninsured people. (2) There is no evidence it will control health care costs. (3) It will force physicians and consumers into large HMOs, with very little choice about their physician. (4) There is at this point no provision for loss of employment—what happens to you if you lose your job as far as your health benefits go? (5) By making health care benefits taxable as they are here, but from a much lower above a certain level, you encourage people to buy the cheapest health insurance, which isn't necessarily the best.

ATC: Clinton has said that everyone would be covered.

SS: Yes, but he didn't say when. It's all speculative, but there's a two-fold concern, first that not everyone will be covered right away and second, that rich can buy supplemental policies that will allow them to opt out of the system. That will leave us with a two-tier health care system.

ATC: And that's not the case in Canada?

SS: Right. The major advantages of system in Canada include universal access to all facilities, and the choice of your primary care physician. You have one card, permanently, you choose your physician, and rich and poor are all in the same boat.

ATC: We hear there are problems now in Canadian system.

SS: There are some delays in getting non-emergency surgery, like knee or hip replacements, but that's not the case for urgently needed procedures. There will be some changes, due to Canada's severe recession (which is partly due to the Free Trade Agreement) and the nearly 50% cut in funding from the Conservative government, which may be partly politically motivated.

Healthcare providers and consumers in Canada are both quite satisfied with their system, especially compared with their U.S. counterparts, and the bureaucracy and billing are much simplified.

ATC:What are the obstxles to achieving a single-payer system in this country, and how are they being confronted?

SS: The political problem facing people in the single-payer arena now is what to do, because single-payer is "not on Hillary's table." There have been multiple union defections, including AFSCME and the UAW (see accompanying article by Rick Wadsworth—ed.).

What can we do? I believe, and PNHP believes, that we have to push for single-payer leislation, while at the same time pointing out the shortfalls of the Clinton scheme and insisting that certain principles be fought for by those who choose to work within the "managed competition" framework.

These principles include universal health insurance for everyone, on the same health plan; broad benefits including long-term care; cost containment through global budgeting and reducing administrative waste, which is probably incompatible with managed competition. In a single-payer system this can be done, without rationing health care.

We demand delinklng health insurance from employment; priority for preventive health services; encouragement of consumer-run, not-for-profit HMOs with salaried physicians; and progressive financing through steeply graduated income taxes (though there are some in PNHP who also support "sin taxes," on cigarettes for example).

Another point made by PNHP is that what they did in Canada was to enact enabling legislation on a national level, then implement province by province. (In other words each province has its own single-payer plan.) There were problems, with some doctors going on strike, but it was much more democratic from the standpoint of people having control of what happened in their province.

ATC: If that happened state by state here, though, there might be big disparities between the care available in, say, New York and Mississippi.

SS: Of course there are potential regional disparities, but the federal government would have to be required to even them out. That is something we would also have to struggle over.

I think the other important thing to say here is that most of us in PNHP don't feel we are in this only for the short run. Particularly because we don't think "managed competition" can work, but it's coming along anyway, we have to stay organized and maintain the fight for the single-payer alternative.

A majority of people, when polled last year, favored single-payer. A majority of legislators favor single-payer. The General Accounting Office did a study in 1988, showing that the money we would have saved from converting the present system to single-payer would have insured every uninsured person at that time, with no cost to anyone. With the plan for MC we are already seeing talk about new taxes, mostly of a regressive character.

Most of us in PNHP think we are part of a much broader struggle, the leadership of which comes from health consumers such as the Northeast Ohio Health Care Coalition and other universal-access advocacy groups, of which we are a part It's a movement organization, not a "professional" one.

We think it's important that consumers and physicians play a role in shaping the new health care system, not Hillary's task force, which as someone has said, "reflects all the faces of America — except they're all lawyers."

May-June 1993, ATC 44

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