Would a one-payer health plan work? Ronald Dworkin's...


September 09, 2000

Would a one-payer health plan work?

Ronald Dworkin's column "Beware one-payer health insurance" (Opinion

Commentary, Aug. 24) was noteworthy for what it didn't mention.

The writer expressed concern for young adults who could be forced to take advantage of employer-sponsored health insurance under a "single-payer" system, rather than opting for being uninsured and having higher wages.

Not mentioned was the plight of hundreds of thousands of Marylanders who are forced to be uninsured or under-insured -- even in these prosperous times.

And the "market-oriented reforms" that the writer supports are typically little more than tinkering around the edges of a health care non-system in disarray.

The Maryland Health Care Commission's 2000 report found that more than half the uninsured live in families with two or more employed adults. Most of them are people in low-paying jobs who are not offered coverage or simply cannot afford the premiums.

The World Health Organization's 2000 report evaluated countries' health care systems based on life expectancy, efficiency and equality of the system and how it responds to the social and financial needs of its citizens. Although we spend more on health care than any other country, the United States ranked 37th.

Canada rated significantly higher in nearly every category.

The United States also has the distinction of being only one of three countries in the industrialized world not assuring health coverage for its citizens, along with Mexico and Turkey.

A truly reformed health-care system must streamline the administrative burden of numerous insurance companies, each with its own maze of benefit rules, referral and authorization processes, billing procedures, forms and marketing, lobbying and profit motives.

A more rational system would generate enough savings (conservatively estimated in Maryland to be half a billion to $1 billion annually, depending on the reforms) to allow affordable, comprehensive coverage to be extended to all citizens, regardless of employment, economic or health status.

Mr. Dworkin exalted more market competition among insurers as the key to better care.

I believe a streamlined system would encourage competition for quality care among physicians and hospitals, rather having insurance corporations compete on the basis of stock prices and profits.

Dr. William Sciarillo, Baltimore

The writer is the president of Baltimore HealthCare Access Inc.

Ronald Dworkin is right on the mark in warning of the perils of a single-payer health insurance system for Maryland.

That health insurance reform is sorely needed appears beyond dispute. The old indemnity system, Hillary Clinton's failed health-care overhaul, present-day managed care -- all of these approaches have been either too expensive, too short on quality or both.

Yet the problems inherent in correcting our system or in crafting a new one are complex. A single-payer system appeals to us because of its apparent simplicity and we, collectively, long for an uncomplicated solution.

Don't be fooled, though. A one-payer system would bring with it the worst of what we've seen with managed care -- an impersonal bureaucracy, unresponsive to the needs of individual patients.

And, in such a monopolistic system, there would be no incentive to decrease cost or increase the quality of care. Only a free-market system generates these incentives.

The single-payer system is indeed well-intentioned, but we would be better off focussing on removing the perverse economic disincentives which currently permeate the health care market.

Free market reform, which restores the primacy of the physician-patient relationship, is the way to go.

Dr. David F. Jaffe, Havre de Grace

Dispersing the poor is no solution

Donald Norris is absolutely correct when he states that "policies need to be adopted at the state and regional levels to reduce the proportion and concentration of the poor who live in the city" ("Addressing Baltimore's population meltdown," Perspective, Aug. 20).

However, his proposed solution -- dispersing poor people throughout the area -- would do nothing but spread the "social pathologies" Dr. Norris looks to correct.

Such a plan would destabilize neighborhoods and destroy neighborhoods already on the edge.

Historically, the idea of moving low-income families into stable or higher-income neighborhoods has been unsuccessful. Residents of Dundalk, for instance, howled when they heard the "Moving to Opportunity" program would bring low-income city residents out to Baltimore County. The pilot program had to be shut down.

And I can personally attest that that such programs do not work. My block in Highlandtown has recently received several families decentralized from public housing.

With little or no experience of living in a community outside public housing, these families have neither the ability nor desire to obey the community's standards.

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