Questions for Dr. Marcia Angell

New York Times "Prescriptions":

Dr. Marcia Angell is a senior lecturer in social medicine at Harvard Medical School and former editor of The New England Journal of Medicine. A longtime critic of the pharmaceutical industry, she has called for an end to market-driven delivery of health care in the United States. She spoke with freelance writer Anne Underwood.

Q. President Obama hopes to increase the number of Americans with insurance and to rein in costs. Do you believe any of the plans under consideration by Congress will accomplish those goals?

A. They won’t, and that’s the essential problem. If you keep health care in the hands of for-profit companies, you can do one or the other — increase coverage by putting more money into the system, or control costs by decreasing coverage. But you cannot do both unless you change the basic structure of the system.

Q. Segments of the health care industry — pharmaceutical companies, for instance — are promising to cut costs.

A. It’s not going to happen. These are investor-owned companies. Their fiduciary responsibility is to maximize profits. If they behaved like charities, heads would roll in the executive suites.

Q. But what about market mechanisms for reducing costs? Wouldn’t the public option, for instance, provide competition for the insurance companies?

A. Theoretically it would, but I doubt the public plan will pass. Industry is lobbying against it, and the president has not said this is a “must.” Even if it does pass, I’m afraid the private insurance industry will use their clout in Congress — and they have enormous clout in Congress — to hobble the public option and use it as a dumping ground for the sickest while they cream off the young and healthy for themselves.

Q. How? Won’t insurance companies have to cover all applicants regardless of health status?

A. It’s hard to regulate an enormous industry without setting up a bureaucracy to oversee it. That’s very expensive and creates a whole new set of problems.

Q. How about the individual mandate? Wouldn’t it reduce costs per capita by bringing in young, healthy people who are currently uninsured?

A. No. In Massachusetts [which enacted an individual mandate in 2006], there is no real price regulation. Essentially what the mandate does is say to people, you will go into this treacherous market and buy insurance at whatever price the companies choose to charge. In effect, it’s delivering a captive market to these profit-oriented companies.

Q. Are people at least getting better health care in Massachusetts now?

A. Massachusetts already spends one-third more on health care than other states, and costs are rising at unsustainable rates. As a result, they’re chipping away at benefits, dropping beneficiaries and increasing premiums and co-payments.

Q. Then what’s the path to meaningful cost control?

A. The only way to both control costs and have universal comprehensive coverage is a single-payer system — a nonprofit, single-payer system. Nothing else will work. All other advanced countries have some form of a single-payer system, and they pay less than half as much per person as we do. We should be asking, why is that so? It’s not because we provide more basic services. We do provide more tests and procedures for those who can pay, but not more basic services — and we don’t cover everybody. So why is it so? We are the only advanced country that delivers health care in a system that’s set up to generate profits, not to provide care.

Q. If a single-payer system isn’t feasible politically, aren’t the current proposals at least better than doing nothing? Isn’t half an aspirin better than none?

A. I think not. As costs continue to soar, people will not say, “That didn’t work. Let’s try a single-payer system.” Instead, they’ll try to pay for the costs in piecemeal ways, by increasing co-pays and deductibles, by limiting services, by making the system less equitable and less comprehensive. I’m afraid the lesson they’ll draw is that universal care is impossible.

But I’m not convinced that getting a single-payer system now is politically infeasible. The public would be happy with Medicare for all. Polls have shown that the public loves Medicare. The problem isn’t the public. It’s Congress, which caves in to special interests.

Q. If Congress is reluctant to cut out the insurance companies, is that partly because they, like the major banks, are too big to fail?

A. A nonprofit, single-payer system would lead to job losses in this sector, which constitutes 17 percent of the economy. But what about the other 83 percent of the economy? They’re being bled to death. Businesses can’t compete globally because the cost of providing coverage to their workers is so exorbitant. Whatever loss of jobs you might see would be more than offset by benefits and job gains in the rest of the economy.

[As for the insurance companies,] you could introduce the program incrementally. You could do it state by state. Or probably better, you could do it decade by decade. Medicare kicks in at age 65. In the first stage, you could take it down to 55. Between 55 and 65, people are vulnerable. They’re losing jobs, losing health care. They’re starting to have more medical needs. After a few years, you could drop it to 45, then 35. It would give insurance companies time to adjust.

Q. But Medicare is already hugely expensive. How can we afford such a plan for everyone?

A. Medicare costs are rising at an unsustainable rate because care is provided in a profit-maximizing system. The prescription drug benefit was nothing but a bonanza for the pharmaceutical industry. I would change that. I would also adjust the fee schedule, which preferentially rewards highly paid specialists for very expensive tests and procedures. For the system to work, it would have to be a nonprofit delivery system.

Q. How much could we save in administrative costs?

A. On average, the private insurance industry takes 15 to 20 percent right off the top of the premium dollar for its administrative costs and profits. That’s a lot to siphon off by an industry that adds almost nothing of value. It’s just a middleman. Medicare has overhead costs of less than 3 percent.

With the money in the system right now, we could cover everyone for every medically necessary service. But the system has to be distributed according to medical need and not as it currently is — as a commodity. Today, those who can pay get lots of M.R.I.’s they don’t need, while those who are uninsured can go without ones they do need.

Q. Military historians say we’re always fighting the last war. Is Mr. Obama now fighting the last health care war, in which Congress rejected the Clinton plan partly because it was developed without consulting other interested parties?

A. Yes. Mr. Obama has decided that he will listen to everybody. But it’s not working for him, because the public can’t become enthusiastic about a plan that doesn’t exist. That’s what he’s asking. Now Congress has gone home, and for the next month the special interests will be out there scaring people with stories of rationing and socialized medicine.

Q. Is the president really bringing everyone to the table?

A. He’s bringing everyone to the table except the single-payer people. It’s very odd. When he was a state senator, he emphatically favored a single-payer system. And in his July 22 press conference on health care, he stated that the only way to provide universal health care is with a single-payer system. Then he moved right on, as if that was somehow self-evidently absurd.

Q. So are you opposing this reform?

A. I am, though not for the same reasons as the Republicans and Blue Dogs. I’m opposing it more in sorrow than in anger. I’m afraid the president squandered a good opportunity.

By Anne Underwood
August 12, 2009