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Posted on Sun, Apr 4, 2010 : 6:09 a.m.

The hype behind the healthcare reform bill

By Guest Column

In the weeks and months ahead, Americans will learn the true details about the health care reform bill passed by the U.S. House on March 21 and signed into law by President Obama two days later. They may not like what they see. If ever there was March Madness, this surely must be it.


Dr. James C. Mitchiner is an Ann Arbor emergency physician.

Lost in all the hype and self-congratulatory rhetoric repeated by Speaker Nancy Pelosi and her Democratic colleagues are the facts that brought us to the passage of this flawed legislation.

Here are a few:

• Of the 32 million Americans who will gain coverage under this law, about 16 million will be covered by Medicaid. Here in financially strapped Michigan, with the recent 8 percent reduction in Medicaid reimbursement to doctors and the looming possibility of an additional 11 percent cut, the already dwindling Medicaid participation rate among physicians will decrease further. The result will confirm what we have learned from health reform in Massachusetts: access to health insurance in no way guarantees access to actual health care. Waits to see a physician will increase, and emergency rooms will become jammed more than they already are.

• Millions of middle-income citizens will be herded into buying private health insurance policies costing up to 9.5 percent of their annual income while covering on average only 70 percent of their medical expenses, leaving them responsible for high co-pays and deductibles. Such a “benefit” will not provide them with the necessary financial security should they fall victim to a catastrophic illness or injury.

• Health insurance firms are likely to garner over $400 billion in federal assistance, courtesy of American taxpayers, to subsidize the purchase of their defective products. Moreover, since the newly insured are likely to be young and healthy, and therefore less risky to insure, private insurers will be guaranteed continued profits which will be used to extend their political clout and inhibit future reforms.

• Workers who currently receive coverage from their employer will be restricted to using their plan's limited network of providers. As the cost of their insurance climbs, many will eventually be taxed on the value of their benefits.

• Optimistic projections that the reform law will reduce the federal deficit are based on wishful thinking and untested theories. As the experience with the Massachusetts reform plan (the model for this bill) has amply demonstrated, health care costs will continue to escalate.

• The much-ballyhooed regulatory reforms in commercial insurance, such as prohibiting denials on the basis of pre-existing conditions, were crafted with the assistance of the insurers themselves, casting doubt on their true effectiveness. Older people, for example, can be charged up to three times more than their younger counterparts, and female employees can be charged higher rates at least until 2017.

This bill’s passage is grounded on base political pragmatism rather than sound health care policy. It leaves intact the fragmented and unsustainable system that is wreaking havoc on our health and economy today, a system that generates up to $400 billion annually in wasteful administrative costs. According to Physicians for a National Health Program, an organization representing over 15,000 single-payer physician advocates, that’s enough to cover all the uninsured and to upgrade everyone else’s coverage without having to increase overall U.S. health spending by one dollar.

So, in the coming years, we will be forced to muddle through the dysfunctional mess that epitomizes American health care. But it is only a matter of time before future legislators will survey the damage done and conclude that only the adoption of a single-payer national health insurance program - an expanded and improved Medicare-for-All - will guarantee coverage for Americans that is universal, portable, affordable, and equitable for all.

Dr. James Mitchiner is an Ann Arbor emergency physician and is the former president of the Washtenaw County Medical Society.


Charles H. Bagley, M.D.

Sat, Apr 10, 2010 : 4 p.m.

The current health care reform debate has not emphasized the most important factor in healthcare reform: physician behavior is responsible for more health care expenditures than administrative overhead and corporate profiteering. Physician behavior is mostly driven by the fee schedule. The fee schedule is set up by the AMA to serve the proprietary interests of the medical profession and the medical industrial complex. Proprietary medicine requires complicated technical solutions to problems that dont solve the problem but create a dependency that ensures a recurring utilization and a steady profit stream (proprietary medicine is necessarily palliative----if we cured disease we would put ourselves out of business). As a practicing physician with 30 years experience, I assert the following: for most patients who are having their condition managed by a conventional doctor, there is some practitioner somewhere doing some kind of alternative medical method which will produce a far superior result at far lower cost. These alternative methods distinguish themselves by not being patentable and/or not being co-optable by any medical specialty. Often they are methods that are developed by nonmedical practitioners (acupuncturists, chiropractors, naturopaths, osteopaths, etc.. I propose an HMO in which primary care doctors skilled in nonproprietary medicine would be given a panel of about 2000 patients ( x $500/month = $1 million/month). All of the expenses of those 2000 patients would come out of the $1 million/month). Over time, if the doctor is successful in eliminating the expensive drugs, surgeries, tests etc. by using nonprietary methods, an excess will accumulate in the account (which can be determined by actuarial analysis) and the doctor can be given a reward. This system would emphasize solving problems at the primary care level, finding real solutions (genuine cures) that create independently healthy patients. The best science would compete with proprietary methods and the best medical methods would prevail. The most sophisticated medicine does not have to be proprietary. Most elective surgeries, many expensive drugs and the cascade of testing and procedures that are patients are so often subject to without benefit can be eliminated at great savings. If we put the research dollars that are currently spent on proprietary products into funding nonproprietary methods we can create an incredible healthcare system. The government should finance this research. This research would then compete with proprietary research and keep it in its proper place.If government funded research got us to the moon, it can certainly cure cancer and the common cold. Methods already exist for these and many other conditions; it merely requires the political will to do it. Charles Bagley, M.D., New York, New York


Tue, Apr 6, 2010 : 9:30 a.m.

I'd like to see more on the interactions between global free trade agreements and our health insurance reform. For example, why did Obama use the promise of a public plan to get elected when our WTO committments on services seem to prohibit new monopoly service providers and commit us to phasing out most of the old ones, committing us to what is, in essence, a "one way road to privatization" (making affordable healthcare impossible without destruction of unions and globalization.) The Canadian Center for Policy Alternatives and Global Trade Watch both have a lot of research on this issue. Here is a good example, a paper which analyzes the effects of FTA's on South Africa's heath reform. It ties their hands. Global Trade Watch also published this report two years ago, but, if anything, the urgency to act on its recommendations is greater now.


Mon, Apr 5, 2010 : 11:54 p.m.

I guess the question is would we rather have a private company provide health insurance where according to some "much more is scraped off the top by brokers, agents, stockholders, claims collectors, claims deniers, claims lawyers, etc, etc, etc." or would we rather have the government provide the health insurance in the form of medicare where the government wastes hugh amounts of money on it's buracuracy? Personally I trust the private sector which has to show a profit to it's stockholders rather than the government which has proven itself to be wasteful and full of buracuracy. Sorry, I used that terrible "P" word!

Bryan Mitchiner

Mon, Apr 5, 2010 : 1:18 p.m.

Don't you think your critiques are a bit harsh? While they may be accurate in pointing to the bill's dangers and uncertainties, and I trust that they are, is the reform not better than what we have today? Better yet, will the reform not produce better results than the situation we would have found ourselves in had we not passed any reform? It would be nice to hear you, and from other practicing professionals that are disappointed with Congress' efforts, give your position on whether or not you believe The Patient Protection and Affordable Care Act is better than not passing any bill. I think many of us understand that the reform bill is not perfect and that it needs more fixing, but is this bill a step in the right direction? Will change arouse more change, ultimately, as you pointed out, leading to a single-payer program? I think it will. For right now, this sense of optimism that cultivates further reform is necessary to recognize.

James Mitchiner

Mon, Apr 5, 2010 : 9:35 a.m.

To Tony Dearing: Please allow me to clear up some misconceptions on single-payer: 1. Single payer is NOT "governmnent-controlled" health care. Rather, it is government-financed health care - and there is a HUGE difference. The model for single-payer is traditional Medicare, which gives patients the autonomy to choose their own physician and hospital. They do not have to "get permission" from Medicare to see a doctor of their choice, they are not restricted in the use of any Medicare-participating hospital, and they are not locked in to using approved pharmacies or clinics. The opposite is true with private insurance companies: they use restricted provider networks to one degree or another. All the feds do under a single-payer system is collect the taxes (in lieu of premiums) which are used to finance health care, and employ global & regional budgeting to control health care costs. Just for comparison, the model for a government-controlled health system is the VA. 2. Private insurance is NOT outlawed in Canada; in fact, from what I hear, about 70% of Canadians have it, as a supplemental policy to pay for health items not covered by the government plan (drugs, vision care, dental care, etc). Also, there is absolutely NO evidence that Canadians are crossing our northern border in droves to get American health care (I can provide the reference for this if you want). It is true that a few Canadians occasionally come to the USA to escape long waits, but in many cases the Canadian government pays for that care to the level it would have paid if the patient received it in Canada. 3. I challenge your assertion that "Most european countries have a two tier system with only the poor using the governement health care systems." Please provide a reference for that. Hope this healps. J. Mitchiner, MD

Marc Williams

Mon, Apr 5, 2010 : 9:03 a.m.

@SonnyDog09 If you own a car the government requires you to purchase insurance.


Mon, Apr 5, 2010 : 8:11 a.m.

FreedomLover, how much more do you thing Medicaid would have cost if it were privatized among many private insurers of choice? Certainly not less - it would cost us more, and we would get less - that's just business. As to the national debt, arguing that as a reason not to provide universal or at list a bit broader health care just doesn't add up. It's like saying "sorry, our city budget is in the read, therefore we are laying off the entire police force and everyone can just hire private security". Well, the city is in a deficit right? We just can't afford to give them this socialized service anymore, right? Everyone should pay their fair share anyway. So now everyone is paying 10%-15% or their annual income on private security for their homes and some collectively for their neighborhood. Had to be done though, because the city couldn't afford police at this time. Unless, well, you don't suppose - no. It isn't possible that we could actually save money by pooling it all together and getting a city-wide police force, could we? Ah, but that would amount to a tax, and government spending, so it couldn't be saving money, no. Talk about cutting off the nose to spite the face. "No, our government can't afford hundreds of billions of dollars a year to provide health care for everyone, so let's leave the government out of this and leave the citizens to spend trillions on their own instead." Even though it would save the people of the US a great deal of money, it would have to be routed through the government as taxes and spending before going to health care, which makes it "bad" to a lot of people. They would apparently rather see this money routed through private insurance companies before it goes to actual health care costs, where much more is scraped off the top by brokers, agents, stockholders, claims collectors, claims deniers, claims lawyers, etc, etc, etc.


Mon, Apr 5, 2010 : 2:41 a.m.

amlive, out current system is unsustainable but out current national debt is more unsustainable. When our country goes bankrupt the least of our worries will be health insurance. Also, I have no problem with reducing overhead costs but the government is not the answer. Just look at how much more medicare has cost over what was first projected and it will soon be out of money. Simple answer, I don't trust the government to run much of anything!


Mon, Apr 5, 2010 : 12:10 a.m.

With the 33 million new insured on the same day how will the medical supply serve the new demand with the same number of doctors and nurses? Won't this be like grinding gears? How will this transition work?

Matt Cooper

Sun, Apr 4, 2010 : 10:03 p.m.

All you Constitutional law experts should spend a few minutes studying the right of federal government to regulate interstate commerce.


Sun, Apr 4, 2010 : 2:53 p.m.

Dr. Mitchener, You should do your next article on "medical tourism" so you can explain to people why Americans are the number one consumers of foreign health services (medical tourism) and why the US is not in the top 10 of destinations for foreigners. Just a suggestion based on what I see from the comments.


Sun, Apr 4, 2010 : 12:04 p.m.

@SonnyDog09 Just to clarify, the government is not "forcing" anyone to purchase health care. If you choose not to purchase it, you're not going to jail, you just end up paying a higher tax. You still have a choice, just like you argue we have a choice whether or not to have a car, own a home, rent a home (where yes, some of the rent still goes toward property taxes), or have any income. Of course if you met all of those criteria, you wouldn't be "forced" to buy health insurance or pay a penalty tax, as you would qualify for Medicaid. If you did have a house, a car, and a job where you made enough money, therefore choosing to buy all those services and pay those taxes, you are also choosing to subject yourself to the "buy medical insurance or pay a tax penalty" rule. By your own reasoning, this is apparently still a choice though.


Sun, Apr 4, 2010 : 10:58 a.m.

To Johnnya2: 1. I am waiting for you to show me where the constitution says the government CAN'T force you to buy something. It's very simple. If you cannot find the power to compel a citizen to purchase something in the Constitution, it does not exist. "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." I don't have to show that the government cannot force this on us. You have to show us where the Constitution gives the government that power. If you cannot, then the government does not have that power. 2. There are a myriad of examples of things you are forced to buy. Auto insurance, police and fire protection, roads, military, a retirement plan (SSI). I have to buy auto insurance if I own a car. If I don't own a car, I don't have to buy car insurance. What is the "if you do x" preface that requires purchase of health insurance? And do you remember when they lied to us about auto insurance and told us that "if everyone has to buy insurance, rates will go down?" I do. Police and fire are payed for out of property taxes. If I do not own property, I do not pay property taxes. Roads are payed for with fuel taxes. Don't buy gasoline if you do not want to pay for roads. Military and SSI are payed for with income taxes. If you do not want to pay for them, make no income. I do not see how any of that relates to the government forcing me to purchase a product.


Sun, Apr 4, 2010 : 10:56 a.m.

Q: "I am waiting for you to show me where the constitution says the government CAN'T force you to buy something." A: Tenth Amendment to the United States Constitution. Thank you, Founding Fathers.


Sun, Apr 4, 2010 : 10:09 a.m.

SonnyDog01 said, "I am still waiting for someone to show me where the Constitution permits the government to require me to buy a product" 1. I am waiting for you to show me where the constitution says the government CAN'T force you to buy something. 2. There are a myriad of examples of things you are forced to buy. Auto insurance, police and fire protection, roads, military, a retirement plan (SSI). In4mation asks, "Why is single payer better? Someone do the math for me. Private sector monopolies are bad but public sector monopolies are good?" I think the simplest answer is PROFIT MOTIVE. There is nothing wrong with a monopoly if there is no profit motive involved in what they are doing. We currently have a monopoly on police and fire service in Ann Arbor. Do you really think it would be more effective to have individual private companies determined by a contract as to how fire and police service is paid for. In fact, I would suggest police and fire protection should be broken down even further and pooled by county. One giant Washtenaw County Fire and Police would be much more effective, especially in lowering administrative costs and multiple chiefs, and other paper pushers.


Sun, Apr 4, 2010 : 9:39 a.m.

Dr. James I agree with your analysis, but not your conclusion. I do not believe more governemnt control will provide better health care to more people. Most european countries have a two tier system with only the poor using the governement health care systems. Canada outlaws private health care and so the affulient come to the U.S. or other countries for treatment instead of waiting months for treatment. Be careful what you wish for soon enough many of us will be forced into the Medicare system without enough Doctors to treat the growing patient list.


Sun, Apr 4, 2010 : 9:08 a.m.

Here you go (in 10 seconds of looking- I could find many better explanations): As a civilized nation, we would never tolerate a system where police or fire services were treated as optional for some residents. To understand how utterly absurd our private health care system is, imagine life in America if we treated police and fire services the way we now treat most health care services. If police and fire services were optional for some Instead of groups pooling their resources and providing everyone with police and fire services, where each dollar spent provides a dollars worth of services (minus the cost to administer payments), imagine introducing a middlemanpolice and fire insurance companies. Like our current health care system, about 30% of every dollar we spend wouldnt provide any police or fire services whatsoever, but instead would go to other insurance company expenses. Aside from administrative costs to pay for services, insurance companies would pay billions to shareholders as profits, plus spend billions more for advertising, lobbying Congress, huge executive salaries, and paying a large staff whose main job would be to find ways to shift costs to purchasers and providers and to maximize profits by minimizing services. Like our current health care system, maximizing profits would mean charging the highest possible premiums (money in) while spending as little as possible on actual police and fire services (money out). This is simply smart business. Insurance companies would compete to enroll residents likely to require the least police or fire services, while trying to avoid residents likely to require the most police or fire services. Like our current health care system, this would guarantee that residents who need these services the most would be the least likely to get them (this is simply smart business). Those residents unfortunate enough to need services too often would be denied, dropped, or charged unaffordable premiums. Those who live in dangerous (low profit) areas would simply be denied police or fire services due to pre-existing conditions (this is simply smart business). Insurance companies would have great profit incentives to find myriad ways to deny services or to shift costs because any money spent providing actual services comes right out of their profits. Like our current health care system, this would guarantee millions of residents would have no police or fire services at all (this is simply smart business). In a civilized society, most health care services are no more optional than police and fire services. Its patently absurd to put a middleman (whose profit incentives are plainly against the interests of the American people) between us and our health care providers. A middleman makes no sense for health services Its clearly counterproductive to put a middleman between providers of necessary services and those who need these services. This guarantees disastrous results. Providing real estate services using a middleman (agent) makes sense. A real estate middleman has profit incentives to provide purchasers with reasonably priced products because if prices are too high, purchasers wont buy and the middleman gets nothing. Theres no profit incentives to deny purchasers whats being provided. Thus middleman profit incentives benefit both purchasers and providers. But providing health care services using a middleman is an unambiguous con game. A health care middleman clearly has profit incentives to charge excessive prices precisely because these services are necessary (pay or die). But even worse, a health care middleman has great profit incentives to deny us necessary services because every health care service denied is pure profit (this is simply smart business). In addition to diverting billions of our health care dollars to profits and other non-health-care expenses, encouraging excessive premiums, and making it very profitable to deny us necessary services, using a middleman also adds hundreds of billions to our health care costs by forcing hospitals and doctors to maintain vast armies of administrators who must battle hundreds of insurance companies (with thousands of different medical plans) all with great profit incentives to deny us as many health care services as they can get away with (this is simply smart business). Then, if you bother to read that, read this: And there are lots more like this.

Alan Benard

Sun, Apr 4, 2010 : 9:05 a.m.

1. Michigan has to address the fact that it does not collect enough tax. It also must adjust spending, but basically the wrong people in this state are carrying the tax burden. Until we have a progressive income tax and Mich Illich pays more than the 4.35 percent on income that I pay, we won't be able to afford to run the state, or pay for Medicare. 2. When I was presented with a BC/BS employment-based plan for my family, the premiums amounted to 33 percent of my gross income. 10 percent of my income for subsidized insurance with a larger pool would be a welcome breath of sanity. 3. The AMA and AARP were among the sane and sober stakeholders at the table pushing for a public option, which would have prevented the profit-taking which the private insurance firms are assured under the defective Senate bill. What could have prevented this? The Republican leadership in Congress choosing to collaborate and build a better bill. We could have had more cost reduction, we could have had better regulation, we could have had a public option to redirect the revenue away from profiteering and back into healthcare. Maybe next time, half our political establishment will behave in a less selfish and cynical manner, leaving the President little choice but to allow the big insurance companies and drug companies to dictate the terms. 4. Access to care being limited to specific networks and providers is nothing new -- the author states the pre-reform status quo.5. All budgeting is based on untested theories. That's why they get adjusted over time. The non-partisan Congressional Budget Office and the Senate Parliamentarian agree that the HCR bills were revenue neutral and tend to extend the life of current entitlements. Again, sound healthcare policy might have been possible if the Republicans had not been so appallingly obstructionist. Should these reforms fail, we need to lay that failure at the Republican Party's doorstep.


Sun, Apr 4, 2010 : 8:54 a.m.

BobR Where is the tort reform? A cornerstone of Republican reform. It is absent as Obama chose to cut deals with the insurance companies, big pharma, unions, and trial lawyers. What is funny is people have not realized they have been screwed by the "transformational" president. Ah, but Obama and his pals are taken care of. The elite voted in March and the masses will vote in November. Something tells me the America people will not be in lock step proletariat formation when entering the voting booth endorsing Obamabot candidates.


Sun, Apr 4, 2010 : 8:42 a.m.

It's easy to just be depressed about where it seems the bill will lead (single payer), if you are opposed to that direction. But how about some more productive solutions? For example, see: for ways that, starting from where the bill left off, we can still improve the system WITHOUT necessarily transitioning to single payer.


Sun, Apr 4, 2010 : 8:41 a.m.

Thank you for sharing your perspective on this James. Of course no health care system is perfect for everyone, and I do believe this current bill may very well help a few more people than it hurts. Sadly, it appears too large a part of our culture still either too complacent, too gullible, or too misguided to realize how unsustainable our current system is, and how little this bill does to change it's fundamental structure. Perhaps in time, as more grow desperate, and more suffer from the failures of this system, there may be enough Americans in favor of a true change in the system to actually catch up with the rest of the civilized world in our approach to health care. Maybe this bill will prolong our agony a bit longer. Maybe when the system inevitably continues to worsen, these baby-steps toward universal health care will be blamed for the failure that was bound to occur anyway, and we'll find ourselves with a public backlash against the change setting us two steps back. I don't know, but I'm not too optimistic. in4mation: The issue here is not about monopolies, it is about overhead in administration and profit. Explain to me how hospitals and doctors having to maintain a sizable staff just to handle billing of dozens of different insurance companies, and pay collection agencies to go after those without insurance, and still have to write off all the bills that are never paid (then recouping that money through government funding or by spreading it out over everyone else's bills), then insurance companies which have huge overhead in administration, handling claims, advertising, and some who still take a profit in the end - how does that system end up more efficient and cost-effective than a single agency that doctors and hospitals bill the same for everyone that comes in? There are just so many middle men in administration, insurance brokers, billing, shareholders, and so many others who take a piece of the pie that could easily be cut out to lower costs with a single-payer system. I have a hard time understanding how this doesn't make clear sense to everyone. Everyone is already paying for the uninsured, whether it be through taxes, health insurance premiums, out of pocket costs, or impacts on our economy from a less healthy section of society. It comes out of our pockets in many indirect ways which aren't clearly itemized on any statements, but believe me, we are all paying for it. Might as well cut to the chase and pay for it honestly, and much more efficiently.


Sun, Apr 4, 2010 : 8:28 a.m.

in4mation: OK, I'll bite. The biggest problems with our "private monopoly" is that it isn't a monopoly, but an oligopoly. That means that the private insurers spend a great deal of money try to make sure that the expensive patients are paid for by someone else. That's expensive and, given that the "someone else" is usually the taxpayer, doesn't serve to keep costs down. As for the overall picture, there are countries (Switzerland or the Netherlands) that have done fine with insuring everyone through private insurance. I don't think the system we're going toward is what anyone would design from scratch, but I do think that it will be a notable improvement and it does seem to be the best thing we can do now toward improving what it is both an incredibly expensive and a very dysfunctional system. We should have done this in 1993 when the Republicans proposed basically this system as an alternative to the Clintons' plan. Had we done so, we'd be better off and in a better position to be fixing the problems we'll discover the new insurance will have. But we have to start where we are, and I think this will prove to be an important start toward a more effective and efficient medical system.


Sun, Apr 4, 2010 : 6:49 a.m.

I am still waiting for someone to show me where the Constitution permits the government to require me to buy a product. If the government can require me to purchase health insurance, what else can the government require me to purchase? A new vehicle from a government owned manufacturer? A smiling portrait of the dear leader to be proudly displayed in every home and workplace? I thought it was illuminating when a democrat representative was asked this question, his response was "I don't care about the constitution." Regarding insurance vs waiting lists vs care, the Canadian Supreme Court wrote that "access to a waiting list is not access to health care."


Sun, Apr 4, 2010 : 6:38 a.m.

It;s true that there are problems with this bill. It would have been far better to have a single payer system, medicare for all or socialized medicine (basically the same thing, different names). But there are substantial reforms in the bill that will make things much better for everyone. This was the most that could get passed at this time. And it's far better reform than the zero reform when the Republicans ran Washington during Bush.