According to the _Shulchan Arukh_, the 16th Century Codification of Jewish Laws, we should prioritize using communal funds for the care of the sick over other obligations, including the construction of a
synagogue. The _Shulchan_ _Arukh_ tells us that health care is not only a priority but also a community responsibility. Today I would like to speak to you about universal health care.

It may seem odd to have a physician speak in favor of universal health care when historically physicians have strongly opposed government interference in, and regulation of, the health care industry. But having been engaged in the private practice of medicine for more than 30 years — and having witnessed and experienced the deterioration of our once model health care system— I can no longer accept the American Medical Association’s position that we have the best health care system in the world, and that all we need to do is tweak it here or there. What this country has at the present time is a chaotic and ineffective system that serves the population poorly. We are all aware that there are almost 50 million US citizens without health care. However, equally worrisome is the fact that there are another 50 million citizens who are inadequately insured — the so-called “under-insured.” In other words, the health care problem is not limited to whether one has insurance; even if one has insurance, there are grave issues with the adequacy of the benefits provided.

I make my case for the support of a universal or national health care program from the perspective of the various constituents involved in that system. First, consider the standpoint of the patient or potential patients seeking medical care. At the present time, a large segment of our population obtains medical insurance through its employers. No one knows for sure, but it is estimated that there is a substantial portion of our workforce that accepts employment positions and stays at jobs that it does not like just so that it can continue to receive health care benefits. The benefits these employees do receive, to a large extent, are the health care plans that are most affordable for theemployer, regardless of the quality of those plans. Clearly, what the citizens of this country need — and deserve — is a standardized health care plan that they can understand, and which is unrelated to employment and geared toward their protection and welfare. Sick individuals need plans which cannot be cancelled at the whim of the insurance company. Overnight, a universal health care program would eliminate the uninsured class and the under-insured class; it also would eliminate the expensive and inefficient state-run Medicaid programs, which support the little discussed (and rarely acknowledged) second class care received by the poor in this country.

A universal health care system would provide standardized and therefore understandable benefits to all citizens. People have very little knowledge of the details of their benefits until they become ill. Under a universal health care system where everyone has the same benefits, family and friends could help one another understand the benefits both before and after an illness. And a true statement of equality under the law would certainly be to have a standard quality of health care for everyone.

What do people deal with at the present time? They deal with companies that are always trying to deny coverage. For example, about three weeks ago, there was a segment on Good Morning America highlighting the experience of a woman in California whose health care company, HealthNet, terminated her benefits when she was half-way through chemotherapy for breast cancer. The woman sued the health care company and recovered several million dollars as compensation for the health care company’s actions. Most shocking to me was the discovery that HealthNet — whose 2007 profits were between $1 and $2 billion — had offered bonuses to employees who found reasons to cancel policies for individuals with high utilization. To earn their bonuses, company employees searched personal medical records looking for something that might disqualify a patient who now had a serious medical problem. The California woman’s policy had been cancelled because she failed to acknowledge that she had elevated cholesterol on an application filed four years previously.
The apparent greed of private health care companies is so pervasive that it is both depressing and demoralizing. This year, Andrew Cuomo, Attorney General of the State of New York, investigated and may well fine United Health Care, the largest private health insurance company in the United States, for manipulating what is referred to as “usual and customary charges.” United Health Care charges extra premiums to individuals who want policies that permit them to use out of network physicians and hospitals. When an individual goes out of network, these policies routinely pay 80% of the usual and customary charge for a geographical location. How does United Health Care determine usual and customary charges? They rely upon a company who claims it uses objective data to calculate that information. However, Attorney General Cuomo found that United Health Care owns that company, and that the company bases its numbers on an average of the fees charged not only for physicians but also for nurses, nurse practitioners, and physician assistants in order to make the “usual and customary charges” as low as possible. In fact, the Attorney General did his own calculations and found that in the New York City area, the usual and customary charge for a physician visit was $200 and not $65, the number determined by United Health Care, thereby costing individuals in excess of $100 out-of-pocket for each physician visit. In addition to United Health Care, 16 other major private health care insurers use the same source for their usual and customary charges. Are people really served well by these companies who seem to be motivated only by profit?

Second, from the perspective of the medical profession, including physicians and hospitals, a universal health care system would be a tremendous cost-saver. The difficulty and expense of billing the insurance companies for appropriate fees, as well as the constant resubmission of forms, requires dozens of extra personnel in billing departments in hospitals and physicians’ offices across the country.

Truly what we have at the present time is a Tower of Babel, with constant bickering as health care professionals and hospitals attempt to be fairly reimbursed for services rendered by companies who, whether intentionally or otherwise, maximize profits by denying services and delaying payments. Private companies continually try to influence medical care by coercing doctors to discharge patients from hospitals earlier than the doctors believe is safe and, at times, refusing to pay for a hospital admission they deem unnecessary. How can they do that you may be thinking? They do it in subtle ways by suggesting to the doctor that he or she can do what he or she wishes but that the patient will be left with a large hospitalbill. The last call I personally accepted from a health care company physician was approximately four years ago: A physician from Philadelphia called me at the hospital and suggested that my patient in room 430 was well enough to be discharged that day. I asked the physician how she could know that without seeing the patient. Did she know that I, a board certified oncologist, and Dr. Decker, a board certified infectious disease specialist, felt strongly that the patient needed to be hospitalized because he had pneumonia and required intravenous antibiotics? The
physician said that the patient’s white blood count was normal and he should do just fine on oral antibiotics. I asked if she was comfortable with her assessment and discharge order and she said yes. I then explained to her that the patient actually had acute leukemia and although his total white count was normal he, in fact, had no normal white blood cells. They were all leukemic blast cells. The patient was critically ill and likely to die, so I certainly was not going to take her suggestion about discharging the patient. Before I hung up, I asked the physician how she slept at night making decisions over the phone, and whether she actually took the Hippocratic Oath, which requires heralways to make decisions based on the welfare of the patient. The physician actually called me a few weeks later to tell me that she took my remarks to heart and resigned her position with the insurance company. She thanked me.

The third perspective that we should consider is that of the employer. It became commonplace in American industry for companies to offer health care benefits at a time when health care benefits were quite inexpensive. In my own medical practice, I recall that 30 years ago, Blue Cross/Blue Shield and Major Medical for a family cost approximately $500 annually. That same policy, with higher deductibles and greater out of-pocket expenses, now costs approximately $13,000 annually, or 26 times what it cost 30 years ago. The dramatic increase in premiums by health care insurance companies has effectively paralyzed American industry, causing companies to become less competitive and acting as an incentive for these companies to outsource manufacturing to other countries. If you think about it, why should the ever-increasing cost of health care be the responsibility of an employer?

The rising cost of health care is something that an employer has no control over and, again, is one of the major reasons why American industry cannot compete with companies in Europe or Asia. A universal health care system in which people pay for health care directly would be a godsend to business and industry at the present time.

The fourth perspective, that of the health care industry, is predictable. These companies have a vested interest in keeping the status quo. Many make more than a billion dollars a year in profit. In fact, in 2007, the top six private health care companies had a combined profit of more than $10 billion. In addition, CEOs and executives earn millions of dollars a year. These companies spend millions of dollars a year lobbying Congress so that the current sub-par system continues. Do you believe that their actions are for the benefit of subscribers or for the benefit of their shareholders?

Several years ago, many insurers adopted software called Claim Check. Why did they do this? The software company promised millions of dollars in savings but was later charged with manipulating claims in a way that cheated doctors and hospitals out of money that they had earned. To illustrate, after one large local health insurer started using Claim Check, it stopped paying for an office visit and chemotherapy treatment on the same day. I notified the company and suggested that it had a software problem. Thecompany’s representatives claimed that it was just following Medicare guidelines. Clearly it was not and, when I was able to prove that this was not in the Medicare guidelines, the company said it was following the AMA CPT codes. Finally, the company told me that this was in fact a new policy change on its part. We negotiated for almost a year until it became apparent that the only way to deal with this computer-generated payment change was to provide the services on different days, even if it would be terribly inconvenient to patients and families. Eventually Claim Check was exposed by _The Wall Street Journal_, which charged their practices fraudulent, and state medical -societies across the country sued. Only then did our local healthcare insurer acknowledge that Claim Check was the problem all along.

Generally, when I bring up the subject of universal health care the overwhelming response is the familiar refrain that the government cannot run anything well. Everyone then mentions the postal system or the interstate highway system, Bbut the fact is that government can — and actually does — run health care well. Most people do not realize that Medicare, a government-sponsored program started in the 1960s during the Johnson administration, actually insures almost 40% of the population and, by my own estimation, 65 to /75% /of all individuals requiring substantial health care. Essentially, Medicare covers the cost of the sick while the private health insurance companies fight over the mostly healthy.
Medicare is far and away the most efficient of all health care insurers with 95 to 97% of all health care dollars actually going for health care. Your average private company, including many of the Blues, spends anywhere from 20 to 40% of the health care dollar on administration. In addition, and I state this from personal experience, Medicare is accurate, provides the best service to physicians and hospitals, pays in a timely manner, and has the best systems in place to settle disputes.

Currently Medicare works through many intermediaries with Highmark Blue Cross being the intermediary for Pennsylvania. It is my experience that Higbmark is efficient and fair to deal with regarding their Medicare services. So when you realize that Medicare is already in place, is government managed, covers the vast majority of sick patients, and has contracts with physicians and hospitals (except for pediatricians), it does not require great imagination to envision a universal health care system as a Medicare-type program. Strangely, when one discusses universal health care, most individuals envision the much criticized Canadian or United Kingdom programs. People, for some reason, fail to consider our Medicare program. I believe that implementing Medicare for everyone would be relatively easy. Medicare already has systems in place to cover all aspects of health care delivery and reimbursement. In addition, Medicare has a mechanism in place to pay for health care.

Everyone currently pays a Medicare tax to the Federal Government as part of their income tax. An increased Medicare tax would cover the expanded Medicare program. One never likes to hear about an increase in taxes.

However, when one considers the vast amount of money currently going to pay the premiums of private health care companies and the enormous cost of state Medicaid programs, I believe that the health care costs per individual or family would be significantly less even with an increase in Medicare taxes with no one, even those in the highest income brackets, paying more than they are already paying at the present time.

Such a system would not only create universal health care coverage, it would enable businesses to get out from under the burden of health care costs and permit hospitals and physicians to deal with a single payer system which would result in dramatic savings from a billing and
reimbursement standpoint.

When you consider that just about all non-third world countries have a universal health care program, how can we assume that we have it right and they have it wrong? Yes, safeguards would need to be implemented to assure fairness to physicians, hospitals and patients, but as with all
programs, the devil (as well as the benefits) is in the details. It is time that we demand that Congress meets its responsibilities to the citizens of this great country and start working on those details.

Clearly, we have an obligation and responsibility to support a universal or national health care program and the sooner the better.

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