EAGLE BUTTE, S.D.— Kate Miner walked into the Indian Health Service hospital, seeking help for a cough that wouldn’t quit.
An X-ray taken of Ms. Miner’s lungs that day, Oct. 19, 2016, found signs of cancer.
What exactly the IHS doctor said to Ms. Miner about her exam remains in dispute. Notations in her medical file indicate the doctor told her to come back for a lung scan the next day. Her family says they never were given such instructions and weren’t told of the two masses the X-ray revealed.
What is clear is that no further tests were done. And no IHS provider followed up when Ms. Miner returned twice more to the hospital, the only one on the Cheyenne River Reservation, over the next six months, medical records show.
These are the opening paragraphs of a front-page story in the December 24 Wall Street Journal. In print it’s titled “A Tragic Journey Through The Indian Health Service.” On line it’s titled “Kate Miner’s Tragic Journey Through the U.S. Indian Health Service.” Unfortunately, it’s gated. The author is Dan Frosch.
I read a recent similar WSJ article on the U.S. Indian Health Service a few months ago. The basic idea in both articles–and there might be others in the series–is that the IHS is doing a bad job.
Why so?
One of the people quoted in the piece, Harold Frazier, the Cheyenne River Sioux tribal chairman, gets at it: “The sad thing is, our people don’t have a choice.”
In the debate among the candidates for the Democratic presidential nominations, various Democrats and one independent, Bernie Sanders, advocate some version of “Medicare for All.”
If we really got Medicare for All, then we would all be saying, correctly, that we have “no choice.”
Does that mean that Medicare for All would degenerate to the point where it would be as bad as the Indian Health Service? Probably not, for two reasons. First, the majority of Americans are less disvalued than people on Indian reservations. Second, there would be places where politically powerful people would probably get excellent medical services. And notice that I said “politically powerful,” not “economically powerful.” There’s an overlap, of course. But they are not the same. The local union leader might have more political power than the 30-year-old hedge fund decamillionaire. And Bernie Sanders and Elizabeth Warren would almost certainly have more political power than the 30-year-old hedge fund guy. What Ayn Rand called “the aristocracy of pull” would be in full swing.
Competition is good and getting rid of competition is bad.
READER COMMENTS
Jo VB
Dec 25 2019 at 8:33pm
I think you are confusing health insurance with health care provision. The Medicare-for-all advocates want single-payer for all, not single-delivery. The problem on the Indian reservation, from what you have quoted, seems to be no choice in what hospital to go to, which possibly contributes to bad service. Most European countries have single-payer health insurance (like Medicare), but patients often have more choice than in the US, where private insurance companies increasingly restrict the network their customers have access to in order to get better prices from providers.
Mark Z
Dec 26 2019 at 1:58am
“Most European countries have single-payer health insurance”
I’m not sure that’s true, at least in the sense of “Medicare for all.” Most countries seem to have hybrid systems rather than full-fledged ‘single payer’ systems like one would see from the Sanders or Warren plans. I think those would surpass most European countries (perhaps not the NHS in the UK though).
I think the issue is that the provider of the service cares about appeasing the payer, not the patient, so a single payer system would in fact have negative effect on competition. It may not matter that I can go anywhere and get treated if the providers are all working for the same monopolist, rather than competing to get patients to come to them instead of someone else, and the value of choice deteriorates if the the quality of all the choices decline in concert.
Admittedly, competition in terms of quality, if not price, can still occur, as providers may still have to compete for funding from the state, but I don’t think competition would be as healthy as a free, private healthcare market. For example, in the UK, quality of care was found to be influenced by how close the margin was with respect to the ruling party’s control (or lack of control) in that district. (http://cep.lse.ac.uk/pubs/download/dp0983.pdf). Essentially, swing districts get better quality care and other districts worse quality, because the former are politically more important. The study also found that higher density of hospitals increased quality, and I worry that the greater centralization of funding we’d see with medicare for all would further privilege big hospital systems and confer or exacerbate de facto local monopolies.
Mark Z
Dec 26 2019 at 2:05am
Oh, and I’d also add that even if your choice is restricted by the network of your insurance policy, you can still choose between policies and networks, so it’s not the same as the hard restriction imposed by a single payer system.
Jo VB
Dec 26 2019 at 9:33am
Doesn’t this strengthens my argument? You link a study that shows that even under the single-payer UK system more competition was beneficial. I would expect this to be even more likely if the providers were independently owned (Not the case in the UK, but would be the case under Medicare for all.)
And you write “competition in quality may still occur”, as if competition in price is a benefit of the US private insurance system. Of course, lower cost, or at least lower prices, is exactly the sales pitch of Medicare for all.
I am sure that Medicare for all has all kinds of disadvantages, but lack of choice and high prices are not the first ones that come to mind.
David Henderson
Dec 26 2019 at 9:45am
You write:
You’re right that I should have made that distinction. And I think the difference does help your argument. But here’s why I don’t think it helps much. With Medicare for All, you do have single payer. That means that someone can’t legally pay for services that Medicare for All covers. So it’s like Canada’s system. In a sense, what we would get is Canada’s Medicare. Would there be pockets where people would get good service? Absolutely. And I discussed that in my post.
And as Mark Z points out, most European countries do NOT have single payer.
Edward Zimmer
Dec 26 2019 at 12:50pm
<blockquote> Mark Z writes: “the provider of the service cares about appeasing the payer, not the patient” </blockquote>
In the case of Medicare this is not true. CMS sets the prices annually (in cooperation with the medical trade associations I believe) & that’s what the service providers receive. Service providers have no influence over CMS (other than thru their trade association).
<blockquote> David Henderson writes: “That means that someone can’t legally pay for services that Medicare for All covers.” </blockquote>
And for Medicare, this is not true. Service providers may not bill patients for services they bill Medicare for, but they may bill patients whatever they wish so long as they don’t bill Medicare.
This is based on my experience of being covered with Medicare for over 20 years (& being very satisfied with service received & freedom of choice).
David Henderson
Dec 26 2019 at 6:24pm
You write:
You’re right. I should have made clear that I’m making a prediction. I think one thing that constrains Medicare is that it is not for all. So there’s still some competition. I predict that if we got Medicare for All, the government would take away that valuable option that Medicare recipients now have.
Alexander Turok
Dec 26 2019 at 4:05pm
Plenty of people are saying that now. If the insurance company won’t cover other providers, you’ve got no choice. You could try to get insurance through another provider, but your employer only gives you coverage through them, who they made an opaque deal with. Your only option is to shop for additional coverage outside employment: Good Luck With That. I’m not trying to be snarkily pro-MFA here. Many of those problems are due to government regs and subsidies. But it doesn’t help your case if you just complain about MFA without acknowledging that our existing system is about as bad.
Comments are closed.