Health care discussed in Maine

Can Maine accomplish a feat that seems increasingly remote in Washington, enactment of a “single-payer” health care initiative? Such a bill, authored by Rep. Paul Volenik of Brooklin, was the subject of a recent forum in Blue Hill. The odds against Volenik’s bill remain long, but that may have as much to do with political defeatism as with the opposition his measure elicits among private insurers.

Achieving universal health coverage is even more important than when President Clinton bypassed single-payer approaches in favor of his Byzantine melange of public and private health care. In 1992, 145,000 Maine citizens lacked insurance. After eight years of boom – and several incremental efforts to expand private coverage – that figure stands at about 180,000. Even a mild downturn will likely increase the ranks of the uninsured. In addition, every increase occasions its own vicious circle.

The uninsured receive some level of care – estimates place the figure at around 60 percent of the insured – much of which they cannot pay for. Those costs in turn are passed on to hospitals and other private insurers, thereby making insurance less affordable for those who remain in the system.

Private HMOs haven’t contained costs. Competition among HMOs is impossible in many communities – especially rural ones. In addition, such competition often emphasizes expensive advertising and surreptitious attempts to discourage enrollment by the least healthy, strategies that raise everyone’s costs.

Thirdly, the private insurers not only extract profit premiums and high executive salaries, they also impose substantial administrative costs. Their own paperwork is accompanied by new bookkeeping chores for physicians. Mark Kandutsch, a Bar Harbor physician speaking at the forum, deplored the amount of office time spent just determining the drugs for which individual insurers authorized maximum patient reimbursement.

A single-payer system, in which all medically necessary procedures would be covered and paid for at publicly negotiated rates, would give Maine residents more health choices. Doctors would have more time to practice medicine. Administrative savings alone would fund the lion’s share of the coverage for those currently uninsured.

These issues have been debated before in Maine. Single-payer initiatives always come up against familiar objections. Some argue that federal employee benefits laws prohibit state health care systems.

Yet this is a misunderstanding. Colin Gordon, a University of Iowa historian who specializes in the politics of health care, points out that “state-level mandates that employers cover their employees are prohibited, but single-payer efforts are not necessarily out as long as they are financed by a general revenue tax or a sales tax.” A state simply could not use a narrow-gauge tax focused on private health plans or the employers who provide them.

Universal health care in Maine would need to be financed by some increase in sales, income, and general business taxes. But businesses and citizens would be trading their private insurance premiums for these taxes. These taxes would increase more slowly and predictably than private premiums have. Nor does Canada’s experience invalidate single payer initiatives. Canadians do face shortages both of emergency room space and state- of-the-art cancer therapies. Yet such shortages are hardly the result of the inherent inefficiencies of the single payer model.

Writing recently in the Toronto Globe and Mail, Dr. Gordon Guyatt, professor of medicine at McMaster University, critiques accusations that the Canadian system wastes money. It has simply been starved: “In 1992, Canada spent 10.2 percent of its GDP on health care. That year, responding to concerns about deficits, the federal and provincial governments began to rein in health spending. Between 1992 and 1997, per person spending on health care decreased across the country. Since 1997, it has picked up again, but we’ve only just returned to 1992 levels of per capita spending. Meanwhile, the economy grew, and we’re spending more on cars, stoves and vacations.”

Canada today still spends 50 percent less on health care per person than the United States. Even with extraordinary public parsimony, Canada achieves overall health care outcomes that surpass the United States.

The constituency for fundamental reform here could broaden beyond the usual progressive suspects. Benefit managers for many companies face escalating premiums and know that managed care is not working. Yet health benefits are a major factor in retaining quality employees.

A state initiative financed by a reasonable mix of broad taxes would stabilize and in the long run reduce their costs of doing business. Lacking a large private insurance industry of its own, Maine’s economy would also benefit by keeping more of its health dollars in state.

The biggest barrier to a single- payer program in Maine may well be the conviction that it is politically unattainable. I believe most Maine citizens, including physicians and even many business leaders, would support such an initiative if it were carefully presented. Volenik’s bill is timely and merits more attention.

John Buell is a political economist who lives in Southwest Harbor. Readers wishing to contact him may e-mail messages to jbuell@acadia.net.