By Anne Underwood
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. 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?
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.
Segments of the health care industry — pharmaceutical companies, for instance — are promising to cut costs.
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.
But what about market mechanisms for reducing costs? Wouldn't the public option, for instance, provide competition for the insurance companies?
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.
How? Won't insurance companies have to cover all applicants regardless of health status?
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.
How about the individual mandate? Wouldn't it reduce costs per capita by bringing in young, healthy people who are currently uninsured?
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.
Are people at least getting better health care in Massachusetts now?
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.
Then what's the path to meaningful cost control?
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.
http://prescriptions.blogs.nytimes.com/2009/08/12/questions-for-dr-marcia-angell/
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