A call for universal health care


The Providence Journal

Two of the most pressing problems facing America are health care, with more than 46 million people uninsured, and our voracious consumption of automobile fuel. I would like to suggest a way to address both problems. I empathize deeply with the uninsured; I am a doctor.

The only sensible thing to do is to eliminate the health-maintenance organizations (HMOs), preferred-provider organizations (PPOs) and all of the various for-profit health-care plans that gobble up enormous amounts of money in the form of overhead, including extravagant executive salaries and dividends for shareholders, and go to a single-payer plan.

A Medicare for all, if you will.

Patients would have their choice of physicians as patients on Medicare do at this time, and as most patients using HMOs or PPOs do not have. Why would this be less costly than the present alphabet-soup insurance plans? Because the overhead for Medicare — as run by our government — is 1 percent to 2 percent.

You read that correctly. The overhead for Medicare is less than 2 percent. The overhead for various private insurance plans (HMOs, etc.) is 15 percent to 25 percent.

The big question, of course, is how to finance a program of Medicare for all. I do not believe it can be done all at once because I do not believe there is, at this time, the political will to do so. The way to bring about a Medicare for all is to cover various groups on a bit-by-bit basis until the plan is universal.

Our voracious fuel consumption could offer a gigantic start toward financing health coverage for many of our uninsured citizens, while also reducing the dollars we send to oil-producing countries that do not have a lot of love for the United States.

Automobile fuel is being consumed in this country at the rate of well over 9 million barrels a day, according to U.S. government figures.

Much of this is consumed by absurdly oversized, gasoline-wasting vehicles. Since our government has been reluctant to use its authority to conserve fuel by imposing strict mileage-per-gallon requirements on all automobiles, SUVs and pick-up trucks, I propose placing an additional federal tax on gasoline sales at the pump of $1 to $2 a gallon and to earmark all this revenue ($140 billion to $280 billion) for health care.

A heavy gasoline tax is routine in virtually all of Western Europe, where one will only rarely find large sedans, pick-up trucks or SUVs. (This past summer I spent a month in England working as a volunteer physician at our largest Air Force hospital, and noted that gasoline there costs, at the current rate of exchange, $7.40 a gallon.)

Such a tax would significantly cut automobile gasoline consumption because people would drive less or buy cars that are more fuel-efficient.

It is estimated that, in 2006, Medicare Part A (hospitalization) and Part B (physician’s fees, labs, etc.) together cost about $340 billion to cover all of our citizens currently under the program (about 43 million people).

Think about what we could do with the revenues generated from the proposed gasoline tax, estimated to be, with a 10 percent reduction in gasoline use due to the increased cost of gas, at $125 billion to $250 billion a year.

If $340 billion was the total Medicare bill in 2006 to cover those 65 and over, even half that amount could be used to lower the current Medicare age limit from 65 to 60 or even 55 — at the very least for Part A, but quite possibly for Part B as well.

Or we could cover outpatient health care for all U.S. children ages 1 to 12, and perhaps for needed hospitalization as well. (I do not propose using the gasoline money to cover the newborn intensive-care nursery because this can be prohibitively expensive.)

If we are to have such a universal system, there will have to be many changes in the way health care is provided and funded. Consider the current physician-reimbursement methods used by the military, the Department of Veterans Affairs health-care system and many, if not most, university medical faculties.

In these organizations, preventive care is emphasized and physicians are salaried.

In a system of universal health care, there may well be physicians who would continue to earn $300,000 or $400,000 — or more — a year by catering to a small segment of the population choosing to remain outside the Medicare system. That is certainly all right.

The government would also have to provide malpractice coverage for physicians working within the Medicare system, exactly as the government now does for physicians working within the military and the VA systems.

(Stephen N. Rous, M.D., is a clinical professor of surgery (urology) at Brown University. For more stories visit scrippsnews.com.)


  1. paolo

    Hi J Hoffa,

    I have some experience in the eyeglass industry. You’re absolutely right: as a rule, eyeglasses are ridiculously over-priced. You mentioned $350 for a pair. Actually, with more expensive lenses, $500 per pair is not unusual. You can get good quality frames on the wholesale side for under $30 (or cheapies for under $5). These are typically marked up to $100 to $300, or more. Single-vision lenses typically cost $2-$3 per pair, and then require a simple edging process to fit the frame. These lenses typically retail for $70 to $100 per pair.

    Fact is, if someone just wants a basic, no-frills set of glasses using their insurance, there is no way they should have to pay anything out of pocket. But third-party payors typically calculate their reimbursements based on something called the “usual and customary” RETAIL prices. Of course, when eye doctors report these prices to insurance companies, as they are required to do, they (as you would expect) jack up the price as high as they can get away with. How do they get away with it? Because the insurance company doesn’t really care, so long as patients keep paying the premiums.

    Of course, if someone wants to pay a few hundred bucks out of their own pockets for some designer frame and fancy lenses, I say more power to them. But the third-party payor system just naturally leads to over-pricing, as the system is currently set up.

  2. Hugh

    For the past twelve years I have been covered by Medicare and also by supplementary insurance from my former employer administered by UHC.

    During this time Medicare has provided more consistent, predictable and prompt service than has UHC.

    If I had a choice between a program provided by Medicare and one by UHC, I would unhesitatingly choose Medicare.

    Based on my experience I would strongly support a single payer system administered by Medicare.

  3. Greg

    The largest cost of medical care are those who want everything, including the newest treatments. Would government ran health care provide the newest and best, for everyone? Or would it be system that the public gets one level, government employees get a better system and the politicians get the best (Germany)?

    Also we have a problem in that many people will not listen to their doctors. In Europe the doctors can refuse treatment, even force assisted suicide on such patients. We have those in the US (ie Dr Peter Singer of Princeton) who feel that those who have chronic illness should be terminated. Switzerland is now allowing the termination of those with extreme mental illness (expensive to treat), Holland terminates extremely sick infants. Would this be our furture?

  4. Lenore

    Jarrod Lombardo, you forgot one thing about raising that $1-$2 gas tax. You’re right, it’ll hurt the poor and middle working class. So where will that extra money come from when they buy gas at the pump? They’ll have to go to the boss and ask for a raise so they can get to work. The boss then has to raise the price of his product or service. So it’s coming right back out of the consumer’s pocket. Guys, there is no free lunch!

  5. charlie

    I have to respectfully disagree with the doctor. The price of fuel and how many miles driven in the UK can not be compare to the USA. The UK has a public transportation system that reaches just about every corner. This can not be said of the USA. I would love to walk to the corner to catch a train or bus to work but its not avaialble. Thats why you and I can not compare the UK & USA. Please stop with the “lets tax gas to get there”

  6. paolo

    I have to disagree with Dr. Rous. The solution to health care is to end government involvement in health care entirely. At the same time, ending professional guild organizations like the AMA, whose main purpose is to jack up the price of medical care by preventing entry of competitors into the field of medicine, would go a long way to solving the problems.

    Make no mistake: the AMA and the government operate hand in glove to screw the American health care consumer.

    Why should we trust these jackals and vampires to solve the problems they themselves have created?

    What we need instead of more government regulation and control of medicine, is to get the government and the AMA completely out of the picture. We need a free market in medical care.

    In a free market system, patients would have a powerful incentive to discuss fees and alternative methods of care with their physicians. After all, they would be paying the bill, at least up to a certain deductible amount. In the current system, especially in HMOs, there is little or no incentive for the health care consumer, the patient, to do this. Thus, we predictably get ballooning costs.

    Third party payers, as a rule, have less incentive than patients to control costs. After all, they just pass their costs on to their customers.

    Doctors usually recoil in horror at the thought of (gasp!) actually having to discuss fees with their patients! They prefer to pass the costs on to third parties, who have much less incentive to control costs.

    Frankly, MDs as a rule make me sick. When they feign their outrage at “ambulance-chasing lawyers,” I just have to laugh. I’m still trying to decide which species is lower–Doctors or Lawyers. Both professions do their dambdest to prevent that nasty aspect of freedom–competition–from impinging on their cozy little professions.

    The best solution to health care would be to close down every department in Washington that deals with health care. Then, close down the AMA.

  7. traderjoe

    There’s a problem with every solution proposed for health care. The problems with the current system are (1) 46 million people without access to adequate medical care, (2)high overhead,(3)no incentive for consumers to be cost conscious, and (4) big incentives for health care providers/organizations to run up costs. That’s four strikes against it.

    A single payer system would take care of (1) and (2) but not (3) and (4).

    A totally private system would not address (1) and (4) and maybe (3) only in theory.

    A Canadian type system, which is government run, would take care of (1), (2), (3) and (4). However, some might argue it would create a (5) inefficient costly bureaucracy.

    I favor the Canadian system. They spend about $2700, adjusted for exchange rate, per capita on health care. The only complaints I’ve seen with it are low wages for doctors/nurses, and lengthy waiting periods for certain procedure like surgery and MRI’s. Also, prescriptions are not included in the basic plan. The question for me is, if we were to adopt the Canadian system and eliminate the waiting periods, adequately pay staff, provide some kind of catastrophic prescription provision, AND include co-pays of $20-$30 for all procedures as incentives to reduce overuse, could we provide such a system by raising the $2700 per capita amount spent by Canada to the $5200 per capita amount currently spent by the US? I’d bet we could provide a gold-plated system for that amount, and probably for less than $5200.

    As for inefficiency, take a look at our current system. It’s hugely inefficient. The whole insurance concept is flawed — it’s like buying groceries and having the bill sent to your employer who hires a 3rd party to pay the bill — 3 guys putting in a light bulb is more efficient. It takes a month + for me to get an appointment to see my doctor through the HMO I use. They do have a walk in clinic. The service I’ve received at the local hospital is scary — they run it like a poorly run government agency. Some of the scams I’ve seen doctors pull to run up bills were truly criminal and should have been prosecuted.

    So I say let’s give the Canadian system a try, with the proper adjustments. When Ross Perot ran for President, he suggested using a pilot project approach to test out various systems on a small scale so we don’t install a huge system all at once that ends up not working. I say we try that approach using an adjusted Canadian system.

    To help pay for the system: adopt a foreign policy not based on militarism, threats, wars; reduce the military to only what is needed to defend our country from attack — close down the 920 military bases in 130 countries; eliminate the crooked military procurement system whereby Lockheed Martin, Halliburton etc. run our defense budget. If we do those things, I’m thinking we can cut $300 billion from the budget, apply $250 billion to the deficit, the rest to health care.

  8. Jhoffa_

    “I have to disagree with Dr. Rous. The solution to health care is to end government involvement in health care entirely.”

    I agree.. The good doctor’s rant about “Big Cars” won’t affect him, as he assumes he will be able to afford something substantial enough to be safe, while the rest of us get little rolling coffins.

    I see no linkage between the two, actually.. While the good doctor sees a cash cow which can be exploited for the benefit of himself and his profession, while Joe Six Pack gets nothing but an additional burden.

    I’d like to fix this problem for the good doctor by depressing his wages.

    That’s right.. I want to drive his wages down. Supply and demand.

    If we’re going to pay for anything, it should be more doctors. We can do this in the form of tax breaks, loan guarantees, immigration changes (We don’t NEED more bean pickers, but a doctor? That’s worth considering.) or scholarships. More doctors increases supply, the demand is there already.

    Likewise, ending Government subsidy’s for health care seems like s good idea. Why? Because it’s my opinion that the minute you subsidize something, the subsidy is absorbed and the costs increase.

    Consider eyeglasses. There’s maybe 20 parts there. The metal stuff costs basically nothing and shaping glass is something we’ve been doing since 1000 AD. So why does a pair of glasses cost $350.00 in some places, while I can get a computer, a real technological marvel, assembled from literally thousands of expensive, specially constructed components, assembled, loaded with software and ready to use.. with a flat screen monitor for $700.00?

    I’d say the difference is there’s no means-based government subsidy for the computer and no insurance to “help” the average family cover the cost. There fore, if you want to sell computers you have to make them affordable, as folks must purchase them with cash out of pocket.

    Perhaps the “free traders” can import come low cost alternative drugs as well.

    Why is it that virtually every other commercial entity here in the United States is told they must “compete” with the entire globe, but low cost drugs from Canada are verboten? I think it has to do with lobby power and money, something I want run out of this industry.

    We need more doctors and we need to lower the bar to entering the medical field. We need competition in the Pharmaceutical Industry and we need to drop medical subsidies.

    The answer isn’t to come up with more money to pay the good doctors astronomical fees and even more to pay for insanely over priced drugs.

    The answer is to increase supply, end subsidies and let market forces adjust these costs to a level which Americans can afford to pay.


  9. Banning all HMOs and PPOs is unnecessary if everyone, regardless of age, is allowed to enroll in Medicare. The market will force the insurers to become more efficient and less expensive.

    The fuel tax thing will hurt the poor and middle class far more than the income from the tax could help them. Nearly all of our country has effectively no mass-transit system. With this lack of public transportation, having a car is necessary to get to most jobs in most places. Making it harder for our workers (including me) to go to work will decrease our quality of life significantly. A fuel tax like the one proposed would only become reasonable after vast public transportation systems are implemented across the whole country.

  10. JimZ

    Just a bit of experience to share regarding this.

    Due to a billing snafu, my health insurance lapsed for a couple of months before I was aware of it. During this lapse, I actually got injured and couldn’t walk without a cane and was in severe pain.

    My point is, when I needed MRI, X-Rays, tests, etc., I had no insurance and was basically a CASH customer. Once that was known, EVERYTHING was cheaper (and probably negotiable) at the hospital than what they were going to charge a health insurer. Now luckily I was able to be treated as an outpatient, so it didn’t rack up as high as it could have.

    It is known that the insurers get “overcharged”, they negotiate it down, and pay something closer to a cash customer.

    Given that, it proves there is room for negotiation, so there is a free market in there somewhere already. However, somehow through the insurance middleman, we end up paying way too much for coverage. I would imagine the Medicare channel through the government has an effect on charges. Obviously they have limits they’ll pay for particular expenses.

    That’s not to say we have a good system, and that’s not to support single payer but what it does say is “how did we get into this current mess”?

    Just decades ago, we could have paid for a home doctor’s visit with live chickens. Whappen?

  11. One way to reduce the costs of medical care in this country is to stop the harrassment of alternative doctors who treat with natural (unpatentable) supplements. There is a movement to eliminate these caring, effective medical professionals who brave the slings and arrows of those, like Dr. Johathan Wright,MD the late Robert Atkins,MD and many others who see the answer to health in a more natural approach to health using non toxic agents which actually can cure and/or strengthen the body and not inflicting poisonous drugs into already weakened bodies.

    The truth is now out: the top killer in this country is not cancer or hearth disease, it’s our medical doctors and their drugs and the hospitals that dispense them.

  12. One answer to our health care system’s burgeoning costs is to stop the efforts of the FDA, the AMA and medical/dental, pharmaceutical professionals from harrassing often taking away the licenses or even jailing the alternative/complementary doctors and other health care professionals for using non toxic remedies that actually cure or prevent disease with support to the body’s natural ability to cure itself.

    The whole medical/pharmaceutical cartel is based on a false premise that taking a toxic poison pill (all patented medications are toxic) will cure diseases. It’s like hitting the tired old mule with a 2 X 4 over the head to get him to pull the wagoon to the top of the hill only to have hhim keel over and die t the top. Since time began, nature has provided remedies in its flora that other animals recognze and eat when ill. Why are we much sicker than other animals? They go out and eat a weed or two when they feel sick. We’d do well to do the same with the help of the real healers, our alternative practitioners.

  13. Fred P

    “Medicare for all” sounds good to me. I’m not certain that your funding suggestion is the best; how about increasing the income tax?

  14. erika morgan

    About medicine the good doctor is right. I’ve worked in the medical profession for the last 30 years. I can tell you that no medical personnel are overly compensated like the insurance and drug companies are. The good doctor is quite incorrect about what the insurance companies are taking for themselves. The agent who sells the plan gets the first 50% for his own pocket, I was married to one for a while so this may be insider info. The insurance company also skims off at least the next 35% for executive compensation. That leaves 15 % of our supposed “medical dollar” to pay for running the insurance company’s business, swank office buildings, and opulent offices; and all the services to the insured patient come last, this is why they always want to quibble over the bill.

    The FDA regulated medical supply companies have also seen this model and found it a leukerative idea. The drugs are marked up 20% to 200% and more over cost with some fake proviso that they need all this money to do research to bring the drugs to market. The rub is that the resurch testings are already paid for by the US Government in the form of university research grants. Drug companies pretend their advertising money is research money, it is the free samples you get from your doctors desk; and they also give me grants regularly in the lab to test their drugs against our local bugs and offer bribes to me personally if I produce the results they want. The medical equipment business has also adopted these corruptions and deceptions.

    We ordered an autoclave (pressure cooker sterilizer) for $1200 from a certain factory, before the machine came I fooled around on the internet and found the exact same machine from the same factory being offered to tattoo parlors for $60.00. Naturally I called the company to check this out and they informed me that it was legitement and that there was no difference in the machines, they also told me that if I was going to incinerate the stuff from the lab that came out of their machine and was not going to use instruments out of the autoclave on patients I could change my order for the cheeper priced one.

    Selling medical insurance and supply is a great cash cow and there is plenty cash there to actually take care of the people if that was what it was used for. The patient on the other hand once he really needs “Health Care” is precluded from producing work to get the cash to pay for said care. Pay as you go has always been the dilemma for the health care profession it’s always been a wrong headed idea. On the other hand the State if it has a healthy work force, vigorous and cared for it will attract more jobs so more tax base. It is in the States interest to pay for a Medicare type system for all its citizens.

    PS1 They have been doing this in Hawaii for years.