How To Reform Health Care Reform Writing in the New York Review of Books, former editor-in-chief of the New England Journal of Medicine and retired M.D. Arnold Relman says President Obama's health care plan won't work. Relman outlines the changes he thinks are necessary for success but missing in the plan.
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How To Reform Health Care Reform

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How To Reform Health Care Reform

How To Reform Health Care Reform

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You're listening to TALK OF THE NATION: SCIENCE FRIDAY. I'm Ira Flatow. Up next, two stories about attempts to reform health care, first the present.

My next guest has been watching our health care system evolve over many years, and he's had a great seat to watch the playing field. He began practicing in the 1940s and was, for many years, the editor of one of the most respected medical journals, the New England Journal of Medicine, and now writing in the New York Review of Books, he outlines the reasons he thinks that President Obama's plan to revamp health care won't work.

Many people on both the right and the left have criticized the president's plan, and we'll be talking with more of them in the next few weeks, as we watch this move through Congress, but few have the credentials that my next guest has.

Dr. Arnold Relman is professor emeritus of medicine and school medicine at Harvard Medical School. He's a retired physician, also, as I say, the former editor-in-chief of the New England Journal of Medicine. Thank you for talking with us today, Dr. Relman.

Dr. Arnold Relman (Professor Emeritus of Medicine, Harvard Medical School; Former Editor-in-chief, New England Journal of Medicine): It's a pleasure to be with you, Ira.

FLATOW: Welcome to SCIENCE FRIDAY. You don't think that the president's plan is going to work.

Dr. RELMAN: No, I don't.

FLATOW: Can you tell us why.

Dr. RELMAN: Well, it's going to work, if the bill gets passed that he wants, it's going to work in the sense that a lot more people are going to have health insurance, but the basic problem with the health care system is not going to be resolved. In fact, it will probably get even worse.

The basic problem is that we can't afford the rising costs of health care. It's breaking the bank. It's breaking in the private economy and in the public sector, and there's nothing in the bills that are winding their way through Congress that effectively controls health cost inflation.

FLATOW: But you said if the president gets what he wants, it will work. What is not in those bills that he wants?

Dr. RELMAN: Well no, I meant - no, I didn't mean that it would work. I think that what the president is asking for isn't enough.

FLATOW: I see.

Dr. RELMAN: What we have to have is a reform not only of health insurance, but of the health care delivery system, because that's where the basic problem lies. The delivery system is inefficient, expensive, wasteful, and it has the wrong incentives.

It's become a business, and as a business, it wants to constantly increase its sales, and until we change that, we're not going to have real health care reform.

FLATOW: Will a federal, as the president talks about, a competitive option, would that work in bringing down the costs?

Dr. RELMAN: No, I don't think it will. We have a federal health care plan now, a huge health care plan. It's called Medicare, and it takes care of everybody over the age of 65, and it does not control costs. In fact, it's going broke.

The health care costs in the Medicare plan are rising almost as rapidly as health care costs elsewhere in the system. So a federal plan is not going to help unless and until we change the way we provide health care.

FLATOW: What would you like to see?

Dr. RELMAN: I would like to see a system that is based entirely on a not-for-profit organization. All-for-profit health care organizations should be replaced by not-for-profit organizations. Doctors should be working for a salary in private groups, multi-specialty groups, and they should be paid on a per capita basis from a central authority, a single-payer authority, which provides coverage for comprehensive care.

The doctors are paid a salary for their time. They don't get paid on a piece-work, fee-for-service basis as they are now, and so they won't have incentives to over-provide care, and because it'll be not for profit and will be regulated, they won't have any incentives or opportunity or reason to under-provide care. They'll do what doctors should do, namely, take good care of patients.

FLATOW: And that will bring - keep health care costs down?

Dr. RELMAN: No question about it. There is a vast amount of evidence that has been accumulated over the years which shows that at least a third of what we now provide in health care doesn't do any good. It is not worth the money. It's unnecessary. It duplicates and spends money unnecessarily, and that would - and the reason there is that excess of expenditure is that there are incentives.

The providers, the hospitals and the clinics and the diagnostic services and the doctors, are paid on a piece-work basis. The more they do, the more they get paid.

If we eliminate that, we eliminate at least one-third of what we're now spending on health care. If we also get rid of private, for-profit health insurance, we also eliminate the unnecessary overhead and business expenses and profits of an industry that is just a middleman between the payer and the doctor and the hospital, and it doesn't provide value for all the money that it costs us.

So if you we eliminate for-profit, private health care, private insurance, and we change the health care system, we'll probably get excellent medical care at 40 percent less than what we spend now, more than enough savings to cover everybody.

Our problem, Ira, is not that we can't afford good health care. We're spending plenty of money now. Our problem is that we have a terrible system.

FLATOW: And how would we pay for it, in your plan?

Dr. RELMAN: Just the way we're paying for it now. The government contributes, depending on how you want to calculate it, the government contributes at least half of the cost through various government programs that are tax-supported. Private employers contribute much of the rest through a tax-deductible system, which is in lieu of wages.

They provide this as a fringe benefit to their workers, and then people pay out of pocket, roughly 10 percent or so, or 15 percent. That money that's now being spent, if it were all bundled together into a central, government-controlled, non-profit system that simply said to everybody, you are covered, every citizen has the right to all the health care that their doctors think they need.

Doctors would be paid on a per-capita basis. They would be working in - I mean, doctor organizations would be paid on a per-capita basis. They would be working in multi-specialty group practices like the Mayo Clinic, like Geisinger, like the Lahey Clinic, like Scott White, Marshfield and so on, doctors working together, primary-care doctors and specialists, on salary, not for profit.

FLATOW: And you could not be turned away for pre-existing conditions.

Dr. RELMAN: I beg pardon?

FLATOW: And you couldn't be turned away if you had a…

Dr. RELMAN: No, absolutely not.

FLATOW: Well, how do you - as you say, you're very pessimistic about actually seeing this happen.

Dr. RELMAN: Well, because it goes against the grain. There's so many vested interests. We have a huge private insurance industry that's making billions of dollars from their monopoly on the insurance, private insurance, non-public insurance. You have hospitals that are competing for patients, not-for-profit and for-profit hospitals behaving pretty much the same way.

You've got a huge number of investor-owned facilities, diagnostic clinics, outpatient surgery, dialysis centers, nursing homes. They're all businesses, and they're making a lot of money from the health care system. They're not going to give this up very easily.

The pharmaceutical industry also makes a lot of profit, more than they need to do what they should do, and they don't want to see the system change, either. They lobby…

FLATOW: So you're saying as long as people can make a profit out of you being sick, they're not going to change that.

Dr. RELMAN: That's right, and they control the legislature by virtue of all the lobbying and all the support. The private, for-profit health care industry and the pharmaceutical industry contributes enormously.

FLATOW: Well, do you think that this is at least a small step in that direction, or as you say before, do you think it's going to be worse because we can say hey, we gave it a shot. Let's move on to something else.

Dr. RELMAN: Well, I suppose that's an optimistic way of looking at it. It may, however, have the opposite effect, that is to say, if we pass the legislation that is coming out of Congress now, we spend a lot more money. We're going to spend billions and billions of dollars more in covering people who don't have insurance now and say that's good, but it's going to break the bank.

There's - nobody is coming up with a plan to pay for the costs. In today's New York Times, Columnist David Brooks, in today's Times, has a wonderful column, which makes exactly this point. He's said it before. I've said it before. I began talking about this 25 years ago, and he says the health care costs are bankrupting the nation.

Health care bills now winding their way through Congress would cover many of the uninsured. They pay for most of the cost associated with coverage. But they would do little to change the fundamental incentives that drive health care inflation.

And he says that until we face that fact, we're not going to get anywhere and I agree with him. And that's what I say in my article in the New York Review. And that's what I document fully in my book, "A Second Opinion," which was published two years ago.

FLATOW: All right, Dr. Relman, it's interesting how conservative and viewpoint of Michael and yours coming together - David Brooks, I mean, and yours coming together, meeting in the middle, saying everybody should see how much this is going to cost.

Dr. RELMAN: Yes. I mean, I don't always agree with David Brooks. He's very smart, very perceptive. I don't always agree with him on all sorts of political issues. But on this issue, he's dead right.

FLATOW: All right. Dr. Relman, thank you for taking your time to be with us today.

Dr. RELMAN: You're welcome.

FLATOW: And it's a very, very good read. It's called "The Health Reform We Need & Are Not Getting," article by Dr. Relman. He talked about it in the New York Review of Books and in his book. We're going to take a short break.

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