Part 2: Readers' and Author's Responses to "We All Need Healthcare; Who Needs 'Insurance'"?

Melvin Stern; Mike Feehan; Georganne Chapin, JD, MPhil


November 29, 2007

To the Editor,

The recent audio editorial on the healthcare crisis effectively highlights the fact that in the world's most expensive healthcare "system," and in one of the wealthiest states in the union, we have citizens who have no access to appropriate healthcare services. As noted, access to health insurance does not necessarily equate with accessible healthcare.[1] The United States spends over $6000 per capita annually for healthcare for every man, woman, and child in the country. This is an amount significantly greater than any other industrialized country in the world. Sweden spent $2745; the United Kingdom spent $2317; and France spent $3048 per capita in 2003.

The question has been asked: "Why isn't there an insurance policy [the poor] can afford?" In this case we again are assuming that a health insurance policy equates with access to quality, cost-effective healthcare. The unfortunate reality is that a health insurance policy represents a product of the insurance industry, an industry whose responsibility is only returning profit on equity. The insurance industry covers nothing. All risk is ultimately carried by the insured, the consumer. When the insurance company pays $100 for a medical service, they charge the consumer a minimum of $122 to cover the "benefit" plus their overhead and profit.

Returning to the issue of how much as a nation we spend on "healthcare," the question remains as to where all the money is going. Equally as important is how do we reduce our total healthcare bill and dramatically improve the distribution of healthcare services? To answer the first question, we need to examine the insurance system. We are now spending almost 30% of our healthcare dollar on administration -- pushing paper, collecting premiums, etc. The response to the second question lies in the fact that talk of providing cheaper health insurance is clearly misdirected. We need to provide healthcare and fund it in a more efficient manner. We need to finally come to grips with the fact that the mechanism we have chosen to distribute dollars for healthcare services is very costly (US overhead costs are almost 15 times greater than Canada) and inefficient. It is increasingly clear that the healthcare market is broken!

The solution is not simple. The debate can no longer be; how can we provide health insurance to more people? We must recognize that we need to provide healthcare and fund it in a much more efficient and equitable manner. An example of the debacle of moving healthcare dollars to the private insurance market is the current Medicaid program in Maryland, which has provided insurance to a greater number of children. In too many instances this new access to insurance has not provided access to healthcare. In many cases insurance reimbursement to healthcare providers is so low that providers will not accept Medicaid patients. The market is working in a very traditional manner. Pay too little for a service and no services are rendered. Although the Medicaid insurers are guaranteed a profit margin, providers are not. The net result is that we have insurers in the market, but healthcare providers have left the marketplace.

To move forward, we must recognize at least 4 important factors. First, there is a lot of money already in the system, almost 16% of our Gross National Product. Second, we must insure the viability of the primary healthcare provider, the doctor, the hospital, the nurse, etc. Third, the administration of the healthcare system cannot be permitted to consume 30% of the expenditure. Fourth, the healthcare market is not a true elastic market. The sick and dying are not free to make well-informed, independent decisions. There may be some role for current insurers to play in distributing funds in the healthcare market. However, their profitability cannot be permitted to consume precious dollars better used to provide medical services. For us to move forward, the public needs to play a much larger role; this may be the ultimate defining role of public health.

Melvin Stern
Highland, Maryland


  1. Chapin G. We all need healthcare; who needs "insurance"? MedGenMed. 2007;9:22. Available at: Accessed November 26, 2007.


To the Editor,

Here in the United Kingdom we have a much flaunted and fanfared National Health System (NHS); however, we also:

  • Have long waiting lists that are kept artificially low and effectively hidden by giving patients an appointment every 12 weeks but no treatment. The same doctor goes through the same questions that the patient answered at the last appointment. Very frustrating for all, but it ensures that the hospital hits its target of seeing a patient before the 12-week limit is up.

  • Have 2 health service systems running alongside each other. Besides the NHS, there are several insurance-supported private healthcare organizations that lately have been fanfaring their services with a tagline that indicates that they have no MRSA [methicillin-resistant Staphylococcus aureus] issues. Obviously, this has always caused a division of resources with both medical services competing for staff, hardly optimal.

  • Pay very high remunerations to consultant level physicians who are able to hold down a position with the NHS while maintaining a position at a non-NHS hospital, and also running their own private practice. They can do so as a result of a nonreversible agreement that was initiated by the administration that created the NHS immediately after the Second World War. Consultants have made it clear that they were opposed to the proposals and would not work for the NHS at all unless it was in place.

  • Are regularly informed by a body euphemistically labeled the National Institute for Clinical Excellence that this or that new medication or procedure will not be available on the NHS because it would not be economically sound. This is something that should surely not be the critical factor when deciding a patient's treatment program but it is, and as a result, it has led to treatments (most recently with breast cancer and Alzheimer's disease) being denied even where they would extend a patient's life span and enhance QOL [quality of life].

  • Have very high rates of MRSA contamination. This is partly due to the fact that the administration did away with hospital matrons who formerly had responsibility for cleanliness and hygiene and then sold the services out to contractors. It seems foolish to assume that a contractor's team on a pressurized timetable would go from one job to the other and would ever be able to replace the formerly well-paid teams of hospital cleaners, where some were attached to each ward, who had their own L' esprit de cour, and had a formidable woman to deal with if the job was not properly done. It should also be noted that many contractors' teams are composed of a mixed bag of low-paid contract and full-time employees -- pay peanuts get monkeys.

  • Have mixed-sex wards, a growing administration fear of overprovision that has led to closers of A&E Departments and Maternity Hospitals up and down the land despite the protests of staff and end users and warnings that they are putting lives in some jeopardy.

  • Have provision of telephone and television services to patients at very high rates of payment. My sister was recently hospitalized in a Southwestern facility, and it cost me almost a dollar a minute to talk with her.

Such are some of the faults that patients have to contend with on a daily basis.

If California, or any other US state, wishes to provide universal health coverage, and I believe it is a viable way forward, they would have to ensure that these issues are fully taken into account and avoided. If they are, then patients will have confidence in a system that ensures the best environment for recovery and the least minimal risk of contracting an infection while hospitalized. Ensuring that consultants are contracted to work for the healthcare system and only the healthcare system will also have some benefits for the profession. Such a system would clear the practitioner's mind and allow him to focus on the patients in his care and only them. It would also lead to younger men being given the opportunity to rise through the ranks as their elders move up and on to private practice and/or teaching positions.

I hope that this letter will air some dirty linen while also promoting discussion and debate of the points raised. A healthcare provider needs to work in an environment where there are no lines drawn as to which patients can receive whichever treatment is needed without having to refer to financial considerations or check whether their insurance covers them for it. Perhaps the United States would then have the premier healthcare system in the world by avoiding the mistakes made by the various political administrations as they applied their own political theories to an NHS that has become more inefficient and ineffective as the years have passed. In my experience, this has obviously had a huge negative effect on patients' confidence so that many are now opting out and purchasing private services.

Mike Feehan
Isle of Lewis, Scotland (formally hired in England)

Author's Reply:

The most recent responses to my editorial of July 27 effectively summarize shortcomings in both the US and the UK healthcare systems. What we need to keep in mind is that any long-standing bureaucracy -- whether the British National Health Service, the US Army, or public education -- is prone to corrosion as a result of changing economic and social forces and institutional inertia. Such organizations tend to change only when necessary, and almost always incrementally, with the resulting accretion amounting to a whole that is far less effective than the invested costs should achieve. Every system needs continual reinvention and reform.

Notwithstanding the problems exhaustively recounted in Mr. Feehan's letter, however, the people of the United Kingdom enjoy better health at a fraction of the cost than the people of the United States. The American population is getting sicker; more people every year have no access to care; and the money we are using to pay for insurance is netting less overall benefit every day. It is no overstatement for Tom Kean, Co-Chairman of the 9/11 Commission and Chairman of the Board of the Robert Wood Johnson Foundation, to characterize the US healthcare crisis as a matter of national security.[1]

To return to my original theme, reliance on the insurance model will only make matters worse. Expecting the free market to deliver equitable healthcare and improve health status for our nation is like asking Blackwater to implement foreign policy. In the struggle between the national interest and private profits, the national interest will always lose.

Georganne Chapin, JD, MPhil


  1. Lavizzo-Mourey R. Aligning the forces of health care for quality and fairness for all. Mabel A. Purdy Lecture delivered to the College of Physicians of Philadelphia, May 9, 2007. Available at: Accessed November 26, 2007.




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