Health care: Book Review, Do Not Resuscitate (reprised)

Published online 8 December 2009.

This is a book review of John Geyman’s book Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It.  Here I argue that the rereading of this book is especially timely as Congress nears the last stages of preparation for a vote upon “health insurance reform” nears.  We need to remember, now of all times, that the fight for health care for all is nowhere near over.

(Crossposted at Docudharma)

Before the current debate ostensibly leading up to the passage of Obama’s celebrated “health insurance reform” bill, John Geyman, M.D., emeritus professor of the University of Washington School of Medicine, (and who also has a prominent blog on the Physicians for a National Health Plan website), wrote a book detailing his critique of the chaos in American health care and his recommendation that it be replaced with a single-payer health care system.  Do Not Resuscitate is that book.  Yes, I am aware that DrSteveB reviewed this book back in January, but his review covered a large number of books, gave only a brief summary, and got only 46 comments.  The other diary on this book here at Orange only received eight comments.  Dr. Geyman’s book, then, deserves a rereading.

Geyman’s indictment of the current system is threefold, as stated in his preface.  1) “The industry today profits by avoiding coverage of sick people, leaving them uninsured or underinsured while passing along coverage of the sick to increasingly beleaguered public safety net programs.”  Thus we cannot trust payment for health services to for-profit entities.  2) “the costs of health care continue to climb,” so you won’t be able to afford it.  And, lastly, 3) “With 47 million Americans uninsured, the number of uninsured is soaring, and cost containment is still nowhere on the horizon. (xvi)”

“Health insurance reform” tries to solve the problem of the uninsured through a false equivalence: forcing everyone to buy junk policies with inadequate subsidies is not “providing health care to everyone.”  This is why it’s important to pay attention to this argument, now.  Do you really expect much from a bill crafted upon the acceptance of a lie?

This book, to be sure, is out of date: its preface is dated May 2008.  And so one has to do a bit of extrapolation in order to update its premises so as to produce a critique of the “health insurance reform” as it stands today.  Here I will try my best to do that extrapolation.

Chapter 1 of this book details the history of health care.  Geyman’s history is one which goes “from spreading risk to avoiding risk and maximizing profits,” (7) as the insurance industry expanded from the role in (mainly) providing insurance through employers, which is the role it had after World War II.  Geyman’s main complaints here are that the insurance industry currently has “limited oversight” (14-15) and that it is rotten through with “consolidation,” thus providing insurers with political power over the economic process. (15)

Chapter 2 is a summary of the three biggest profitmongers in the health insurance industry, with occasional glances at their predatory practices.  The big three are Wellpoint, which cherry-picks its customers, United Health Group, (which sells scanty policies to healthy college students), and Aetna, which has cut back on its actual coverage of the sick of late.  Here’s a sample quote:

Wall Street maintains an especially close watch on MLRs (medical loss ratios).  When a fourth-quarter 2006 MLR came in at 81.1 percent, down from 81.3 percent in the third quarter but higher than the 2005 level of 79.9 percent, for example, Wellpoint felt compelled to reassure investors that its premium pricing would outpace medical costs.  (30)

For those who don’t know: “medical loss ratio” is the percentage of expenditure upon medical cases which actually goes to medicine, as opposed to administration and profits.  If they tell you that the actual profit rate of the health insurance business is “below 5%,” well that’s just creative accounting.  Ask to see the medical loss ratios.

Chapter 3, “From ‘Cherry Picking’ to ‘Denial Management,'” is about how the insurance companies profit off of malicious practices.  Geyman gives a list of these, and they include:

  1. practices that limit access, and these are summarized in terms of underwriting guidelines to deny coverage.  When coverage is required via “health insurance reform,” these will become guidelines to deny care.
  1. practices restricting choice, which allow insurers to dump expensive forms of health care while channeling care to facilities owned by the insurance companies themselves.
  1. practices limiting the value of coverage, i.e. junk insurance, which doesn’t really cover you but at least you get to say “yes” when the secretary asks you if you have insurance.
  1. practices that reveal the industry’s lack of integrity — this category covers a wide variety of forms of lying and fraud, including:

a) inadequate disclosure
b) inappropriate disclosure
c) deceptive marketing
d) conflicts of interest
e) devious dealings with physicians
f) profiteering through insider stock sales
g) outright fraud

So, yeah, there’s a lot of sh#t goin’ down.

Chapter 4 is titled “Myths and Mirrors: How the Industry Perpetuates Itself.”  This is a myth-debunking chapter, in which untrue assumptions about the industry are rebutted.  The fundamental problems revealed in this debunking are those of a for-profit insurance system attempting to “cut costs” by denying people access to care, thus increasing mortality rates and overloading emergency room use.  We are also told that the government funds about 60% of health care costs; this is, then, an attempt to refute the “free market” ideology which keeps the insurers in business.

Chapter 5 claims that the health insurance industry is “An Imploding Industry On A Death March.”  The problem with such phrasing is that it’s hard to tell precisely who is going to die — us, or the insurance companies?  I think it’s us who die.  But if you kill enough peasants they will start to revolt, and form lynch mobs.  We shall see.  At any rate, here are Geyman’s reasons for saying this:

  1.  Growing health care costs
  1.  Growing unaffordability of premiums and health care
  1.  Decreasing levels of insurance coverage
  1.  Fragmentation and inefficiency

Generally speaking, we’ve been over these reasons before.  Moving on:

  1.  Shrinking markets

Most insurance has been employer-funded, although here we are told that the shift away from employer-funded health insurance has been “dramatic.”  (100)  Generally speaking, the reduced levels of employer-funded health insurance have been compensated by — nothing.  Page 101 tells us: “A 2006 study by the Commonwealth Fund found that 89 percent of Americans who explored getting individual coverage between 2003 and 2005 never purchased a plan.”  People just can’t afford it.  No wonder the companies are so desperate to get that mandate in place!

  1.  Subsidized markets are also vulnerable — what happens is that the corporations abuse the public plans (Medicare, Medicaid) and then fall prey to lawsuits.
  1.  Ineffective State and Federal Regulation — we’ve been over this before.
  1.  Growing Economic Insecurity and Hardship, Even for the Insured — here, Geyman touches upon the economic downturn, in a relatively early stage as of the time of writing of this book.  But I’d like to depart from script, here, and explore this suggestion a bit further.

On p. 112 Geyman starts to make his summary argument: “Why We Must Discard Private Multi-Payer Financing” for health care.

Chapter 6 discusses incremental reform.  “A recent RAND study found that government subsidies which cut health insurance premium costs by one-half would reduce the number of uninsured by only 3 percent.”  (133)  High risk pools are “largely ineffective.”  Association health plans are “not-for-profit false fronts for their own for-profit marketing.”  (133) Disease management programs are granted this conclusion, again via a RAND study: “there is little evidence that these programs can actually save money or improve health outcomes over the long term.” (133)  Pay for Performance plans and more efficient use of information technology will not “do the trick.”

All of Geyman’s citations of evidence should have delivered a stern warning to the people in Congress writing 2,000 page bills meddling with “health insurance reform.”  Congress is simply not going to be able to “reform” the existing system in any workable way, because it’s based on the maintenance of profit-making corporations which increase margins through the denial of care, and because the government is simply not going to find enough money from some other source to pay for the rising costs of health insurance (assuming that regulation requires the companies to pay for an increased incidence of care).  Obama’s insistence that reform be “revenue-neutral” ups the ante even further.  Which do you like worse: high premiums, or high taxes?  Thus “health insurance reform” is likely to be a variant on the a failure, i.e. a failure.  Geyman concludes:

We are almost certain to see increasingly unaffordable insurance premiums with less coverage, growing ranks of the uninsured and underinsured, further fragmentation of risk pools, erosion of safety net programs, and increased morbidity, preventable hospitalizations, and deaths.  (138)

Chapter 7 is about “The Industry’s Rearguard Actions.”  This is a discussion of what the insurance industry was (at the time of writing) trying to do to prevent reform.

Chapter 8 addresses single payer: what would it look like?  here are its main assets:

  • Evidence-based coverage: make sure drug and medical device industries offer cost-effective solutions to medical problems
  • Reimbursement reform: make sure pay for primary physicians is equitable
  • Strengthening of primary care: more primary care physicians
  • Quality improvement: better care for all
  • Transition from For-Profit to Not-For-Profit System: get the profit-mongers out from between you and your doctor
  • Rebuild the Capacity of Government: Get the anti-government people out of government
  • Malpractice liability reform: huge “jury awards that are devoted to paying for medical costs incurred by malpractice will be eliminated under NHI, since the government will pay physicians and hospitals that perform the corrective care.”  (202)

So who would be the winners, who would be the losers, with a single-payer system?  The winners would be the businesses, the working class, the physicians, and the medical community.  The losers would be the health insurance industry and the drug and medical device industries.

Geyman concludes by arguing that single payer reform is possible now.  His argument here is not entirely persuasive — it does not appear as if the single-payer advocates are sufficiently organized politically to withstand the financial onslaught of the health insurance industry.  Indeed, in her most recent pitch to the single-payer people, Jane Hamsher said this:

The weakness of single payer clout was evidenced this year when none of the 88 cosponsors of H.R. 676 worked collectively to get a CBO score.  Withholding even a handful of votes from the war supplemental, or the stimulus bill, or cap and trade could have made that happen.

Instead, Democrats like Charles Rangel and Henry Waxman withdrew as cosponsors.  After collecting donations from single payer supporters for years, once their votes counted they were nowhere to be found.  Joe Baca, Eddie Bernice Johnson, David Scott stepped forward and said  they will not even vote for it if it came up for a vote.  And Andre Carson, Linda and Loretta Sanchez, Betty Sutton and Jim Moran wouldn’t commit.

Why did they feel they could do that?  Because they felt safe in the knowledge that there would be no political consequences.  And there were none.

In future election cycles, then, we must be prepared to kick Congress’ and Obama’s butt to make sure single-payer reform is “on the table.”  Otherwise we face a long, dreary band-aid period on the way to minimally-effective reform, with not a whole lot of hope against rising premiums, ineffective subsidies, cherry-picking companies, the gutting of Medicare and Medicaid, the persistence of the category of the uninsured, and so on.

And just to press the point home, I don’t buy ANY of this crap about how Congress will only consider “health insurance reform” fifteen years from now, so we better make sure the bad bill passes “or else.”  There are too many people being ripped off by the existing system now, far more than there were in 1994, and there will continue to be too many people ripped off by the existing system next year, whether the bad bill passes or no.

As for the “public option,” and the current bill?  The debate on the “health insurance reform” endgame is covered better over on firedoglake than it is here.  I suppose the most proactive discussions today are about the expansion of Medicare to 55 and up.  That could be the preview of an ultimate expansion of Medicare to everyone.  The rest of it, as Geyman would argue, is a mixed bag, but mostly crap.

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