There is great concern about the cost of providing universal health care coverage. How can we afford the costs of such a program when our present program appears to be more than we can afford?

It is important to recognize that the insured public already is paying a substantial part of the costs of the uninsured. The uninsured use the emergency rooms, and the hospitals are prohibited by law from turning them away. The cost of this “free care” is paid for in one of two ways: either through higher charges on the paying users of hospitals, or by endowment income and donations. The hospitals have to at least break even to stay in business—there really aren't any other alternatives—and they stay in business by raising the charges on their paying (insured or otherwise) patients to cover the costs they do not recover from non-payers or partial payers. Now you know one of the reasons why the cost of health care insurance continues to escalate more than most other services.

Since we already are paying for much of the services being provided to the uninsured, it would be far more cost-effective to move them out of the emergency rooms into clinics where they can be served in an appropriate environment and in a much more efficient fashion. We would further benefit from unclogging the emergency rooms so that it would be possible for the folks who really need emergency service to get it on an emergency basis.

I'm sure the costs would still go up because folks who are uninsured often don't seek the medical care they require—in the emergency room or otherwise—because of their inability to pay. Presumably many of them would seek medical attention if it were no longer necessary to pay for most of it. Consequently, we should expect total utilization to increase.

A part of the total cost of universal coverage should be reduced by using a single government-based payment system and by the better use of primary care physicians and other medically trained personnel. In the future it is very likely that more “first responder” medical care will be provided by medically trained personnel with less training than M.D.s, such as the services currently provided by registered nurses at supermarket and drugstore clinics. Those patients requiring more expert attention either will seek it themselves or be forwarded on to more highly trained medical personnel. Some of the good doctors my family uses today utilize their medical assistants to screen patients and, when appropriate, provide initial care.

It would be wonderful if we could afford for every patient to see a well-trained and up-to-date doctor for every ailment, but using other professional and paraprofessional personnel will be better than having a great many people not receive any professional medical assistance at all and will help in containing costs. For those patients who can afford to pay more for direct access to the doctors of their choice, they should be able to do so, and doctors should be able to charge them accordingly. Some patients with limited resources may prefer to spend them on higher cost care, and I think that they should be permitted to do so.

Whether we stick with our current insurance-based program or move to a single-payer system, we are going to have to find a way to produce more well trained medical personnel. If we also move to universal care the need for more medically trained personnel will increase even more. An article in the Atlanta Journal-Constitution on Jan. 8 tells us that there is a chronic shortage of nurses that has led to understaffing, threatens patient care and undermines nurses' job satisfaction, and the situation is expected to get worse. “The U.S. Bureau of Labor Statistics predicts about 233,000 jobs will open for registered nurses each year through 2016, on top of about 2.5 million existing positions,” the article stated. The shortage is so severe that it is difficult to find qualified instructors to staff the training programs necessary to address the problem, according to the article. We have similar problems with the supply of doctors, which has been alleviated in part by hiring foreign-trained doctors. Expanding health care coverage will make this problem worse.

Any program of universal coverage is likely to preserve a co-pay feature that would require all users except the truly indigent to make a payment at the time of service in order to discourage unneeded exams and consultation. Studies published in the McKinsey Quarterly, a publication of the management consulting firm McKinsey & Co., tell us that there is a direct correlation between economic incentives/constraints and consumption of medical services.

Some folks think that costs would go down if everyone were covered (or at least the costs would not go up as much) because serious illnesses would be caught earlier and people would live longer in good health. There appears to be general agreement that the total cost of the health care system could be reduced by a more effective focus on reducing lifestyle induced illnesses. A related idea is to charge folks who engage in unhealthy lifestyles more for their health coverage, either based on use of services or by higher Federal Insurance Contributions Act taxes (which are likely to be continued even with a single-payer, universal coverage system) on the assumption that such additional charges would encourage smokers and others to reform their lifestyle and thus improve their health. When I have advanced this proposal myself, I have been reminded that to the extent people live healthier lives and thus live longer, they will be entitled to more payments from Social Security with the result that at least some of what we gain on one side will be lost on the other.

And we will all die eventually no matter how good our lifestyles and health care. Will our delayed fatal illnesses be less expensive to treat than the ones we might have experienced earlier by living less healthy lives? This answer appears to be “yes” and that surprised me. One of the McKinsey studies indicates that “the high incidence and cost of treating lifestyle- and behavior-induced diseases, such as obesity ... are responsible not only for a majority of the deaths in the United States but also for the fastest-growing share of health care costs.”

“About two-thirds of all deaths in the United States now result from chronic diseases most often induced by behavior and lifestyle—for instance, obesity and related chronic conditions…, smoking-related cancers and alcohol-related liver disease,” according to the McKinsey study. To this list one of my doctor friends would add sexually transmitted diseases.

“The incidence of clinically defined obesity in the U.S. adult population has more than doubled, to 34 percent, since 1980. The average annual cost of health care claims associated with morbidly obese patients (the fastest-growing category of obesity) is more than $7,500 a year, nearly twice the average for adults who are not obese … ” according to the McKinsey studies. If we could reduce obesity to the 1980 level, McKinsey estimates that the savings in health care expenses would be approximately $60 billion a year.

Larry Summers noted in a recent article in Harvard Magazine that research conducted by University of Washington Professor Christopher Murray found “that less than half of hypertension in the United States is discovered, and of that half, less than half is controlled—for a disease whose costs and consequences are great, and that we know how to detect and treat effectively and cheaply.” Several of my doctor friends agree that we could substantially and inexpensively improve health outcomes in the U. S. if most everyone over 50 years of age took a statin, an ace inhibitor and an aspirin every day.

Advances in medical science have made it possible for people suffering from chronic diseases to live much longer and at a substantiality higher cost. Another important health care expense issue is the cost of prescription drugs. They are much more expensive in the U.S. than in most other countries. Americans spend about $98 billion more on prescription drugs than would be expected in comparison with other developed countries, not because Americans use more drugs, but because they cost 50 percent more here. Part of the reason is that U.S. drug purchasers pay a high percentage of the total global pharmaceutical research costs of $40 billion to $50 billion a year.

The Bush administration made the decision to prohibit Medicare from negotiating with U.S. pharmaceutical companies for lower drug prices in order to support drug research. However, the national health care systems in other developed countries are not prohibited from negotiating for lower prices nor is the U.S. Veterans' Administration. Loading most of the cost of drug research on us is a poor solution to what is an important international problem.

Another source of wasteful and unnecessary prescription drug costs assaults us on television and in the print media at every turn (especially the evening news), and that is the advertising of prescription pharmaceuticals. Most developed countries restrict direct physician or consumer advertising. Pharmaceutical companies in the U.S. spend between $30 billion and $40 billion a year on sales and marketing of prescription drugs, which accounts for 17 percent to 23 percent of the cost of such drugs here. Included in these costs are direct marketing to physicians.

If you have ever wondered who are all those good looking, stylishly dressed young people with briefcases in the elevators of your doctor's medical office building around lunch time, some may be doctors or nurses, but most of them are well paid pharmaceutical sales personnel. These advertising and marketing costs do next to nothing to improve the quality of your medical care and could be saved if the advertising and direct marketing of prescription drugs were prohibited.

Direct advertising has at least two other unfortunate results that further increase the cost of medical care in the United States. Doctors are compelled to defend treatment decisions with patients who believe everything they hear or see on television, and this takes time and adds to the cost of services. In addition, the drugs advertised often do not represent a significant improvement over generic or less expensive drugs that could be prescribed for the same ailments. Rather than argue with patients about the relative merits of the competing drugs doctors often prescribe the newer and often more expensive drug.

Michael H. Trotter, Special to the Daily Report