State secret

If two new reports see daylight, they could put radical health-care reform back on the agenda in Massachusetts

Medicine by Tinker Ready

If you click on the Massachusetts Medical Society Web page and search for two new reports on health-care reform, you find the links and then hit a cyberspace wall. The documents -- which reportedly come out in favor of a Canadian-style health-care system for Massachusetts -- are off-limits to everyone except members of the medical society. The organization is refusing to release the studies until members can debate them at their May meeting. Consumer advocates say the doctors' group wants to keep the reports hush-hush for as long as possible because members don't agree with the findings. If that is the case, though, the doctors' reticence could backfire. The tug of war over the reports may very well re-ignite long-dormant interest in the Canadian "single-payer" approach, which supporters say offers a solution to our current health-care insanity.

"These results have shaken up the medical community," says state senator Robert Travaglini (D-Boston), who supports the Canadian approach.
"It has shifted the spotlight back upon the single-payer system."

The documents reportedly spell out how the state could work a miracle -- provide health insurance to the uninsured and save millions, or perhaps billions, of dollars. Sound too good to be true? It is, if you're particularly attached to the private insurance industry or averse to getting your health coverage from a state agency.

Under the single-payer approach, the delivery system -- doctors, hospitals, clinics, and drug companies -- remains private. But the private insurance industry -- including Blue Cross and all of the HMOs -- disappears, and is replaced by a state-run health plan. So instead of paying premiums to your employer, you pay extra taxes to the government. The savings come mostly from cutting out the profits and the middleman. It's an approach that the Massachusetts Medical Society has rejected in the past, but one that is embraced by a coalition of medical and consumer groups called Mass Care. For years, Mass Care has been trying to get the state legislature to pass a bill that would explore the possibility of a single-payer system. The bill is up for consideration again this year, and Mass Care wants the MMS to release its data in time for legislative hearings scheduled in March and April.

The MMS has said no.

"These reports were developed for internal discussion purposes," says MMS president Marylou Buyse. "It is our policy not to release such reports until they are approved for release by our house of delegates."

But that was not the understanding of the Mass Care activists two years ago, when the Senate Ways and Means Committee decided to rely on the planned MMS reports rather than sponsor its own study, says Mass Care president Richard Mason.

"We were very clear that we wanted to have the results ready for [the] hearing in the spring," he said. "We feel that legislators need this, and legislators have told us that they won't sign on until they see the data."

So far, only MMS members and Ways and Means Committee members have been granted access to the reports. Professor Alan Sager and analyst Deborah Socolar, of the Access and Affordability Monitoring Project at the Boston University School of Public Health, did much of the work. They've been tracking Massachusetts's insurance trends ever since the state's ill-fated 1988 attempt to implement universal health care. Socolar says she's not at liberty to talk about the findings.

"It's their report," she says, after a long pause. But she does confirm that the research puts the single-player plan in a "positive light."

"The evidence indicates that it would be possible to cover everyone comprehensively and spend less than we are spending on health care today," Socolar says. Some of the numbers in a report on the uninsured in Massachusetts, done last September by the BU team, tell the story. In 1996, the US -- the only industrialized nation without national health coverage -- spent $3898 per person on health care. That's more than any other country in the world. In Massachusetts, the tab for everything from prescriptions to doctors' fees to crutches to MRIs added up to about $5060 per person. That's probably the highest per capita health-care spending in the world, and it's more than twice the per capita rate of Germany ($2233), Japan ($1673), or Canada ($2065), where everyone has guaranteed health-care coverage. In the US, more than 40 million people have no insurance. That includes 755,000 in Massachusetts, up from 495,000 10 years ago, according to the BU report.

In the report, the BU researchers estimate that, in 1999, Massachusetts residents will pay about $35.4 billion for health-care services. If the state were to switch to a single-payer system, the tab would be about $34.5 billion.

Some health-care reformers managed to get the single-payer system on the national table in the early 1990s, but it has always been a long shot. The notion of a government-run health-insurance program conjures up images of crowded clinics and overworked doctors. Virulent opposition from the insurance industry and the American Medical Association helped steer policymakers toward incremental reforms that would expand coverage but preserve private insurance. The result was the Clinton administration's cumbersome "managed competition" plan, which crashed and burned in 1994, taking the impetus for health-care reform with it.

It's news to Robert Hughes, president of the Massachusetts Association of Health Maintenance Organizations, that anyone is even talking about the single-payer approach anymore. He says he is unaware of the debate over the MMS studies but doubts that anything will revive interest in the single-payer option.

"I'm surprised that people think it still has a chance," he says. And for those who point north as an example, Hughes cites recent news reports about long waits and poor care at Canadian hospitals.

"The Canadian system is in meltdown," he says. Indeed, several years of tight budgeting have hurt the quality of care in Canada, which serves as a model for the single-player plan. Last year, doctors in British Columbia went on strike, and this year, patients are coping with long waits for doctors' appointments and hospital beds. Even among critics, though, there is little talk of scrapping the system.

Back in Boston, some on Beacon Hill want to press the MMS to release its reports in time for the spring legislative hearings. More likely, the hearings will be postponed until after the doctors meet in May. But supporters of the single-payer bill worry that a delay could kill the proposal by pushing it to the bottom of a crowded agenda. On the other hand, private insurers are not winning any popularity contests these days. If activists start talking about the single-payer system again, they may find the public more ready to accept the radical changes it would require.

"The number of uninsured is going up and the costs are going up," says Mass Care's Mason. "The problem isn't fixed. . . . There is a time when people are willing to accept sea change. There are going to be powerful political forces lined up against single-payer. But I think the numbers are in our favor."

Tinker Ready, a freelance science writer living in Cambridge, can be reached at tinkerr@mindspring.com.