Here's Why We Need a Single Payer Healthcare System

When I lost my vision in 2005 and began looking for help I found the VA system.  In order to get help with blind rehabilitation I had to become a VA patient which involved a little patience.  At one time all veterans were eligible for healthcare through the VA, but the load on the system required the establishment of a tiered system of care based on need, period of service, area of service, a service connection to the veteran’s health concern and other factors.

I had private insurance, so I wasn’t eligible on the basis of need, but I had been in Vietnam during a period when I would have been exposed to Agent Orange, and blindness is considered a catastrophic disability.


 After about 10 months I attended the Blind Rehab facility in Augusta, Georgia, learned a lot of skills related to getting around and living and received training on a computer using an accessibility program for the blind and visually impaired.  I’m writing this on a computer supplied by the VA loaded with ZoomText.

From 2006 to 2015 the rest of my healthcare consisted of annual physicals and blood pressure medication.  And then during the spring or summer of 2015 I developed a lump on my leg.  I had it biopsied in October and was given a return visit date two weeks later to take out stitches and go over my pathology findings.  Four days later I got a call from the surgeon telling me that I had a particularly malignant form of skin cancer, and he wanted to refer me to Duke Medical Center for further evaluation and treatment.

It was a terrifying time.  Having worked thirty years as a pathologist I knew the implications of the report and in November I was evaluated for spread and scheduled for surgery. 

I had a wide excision of the biopsy site and a skin graft at the beginning of December, and was sent home after five days of lying in bed with a drain and suction over the graft and proceeded to recuperate.

A wide excision is, well, wide.  It took about a month for the pain and swelling to begin to subside. 

All seemed well until September of 2016 when I became suspicious of a couple of lumps near the previous surgery.  A biopsy showed that they were cancer.  There was a lot of discussion about whether these were regional spread or a skin metastasis, since they were on the other side of my leg.  The implications were significant.  Regional spread could be treated locally.  A metastasis would require systemic treatment like chemotherapy.  All of the studies showed only cancer in that area so the decision was one of either amputation or radiation.

Because of my age and the fact that I would probably not make a successful transition to a prosthetic, radiation was considered.  There are immediate and long term risks to radiation.  Immediate risks are of damage to blood vessels or nerves or to joints that might make amputation become necessary.  A failure of the radiation would also mean an amputation.  Long term risks were secondary cancers like bone cancers or another malignant skin cancer.

For most of November and December of 2016 I underwent radiation.  I was fatigued, had symptoms like a bad sunburn, and my skin graft really took the insult poorly.  Parts of the graft were covered by blisters like a bad subburn, but gradually, with the right treatment recovered almost completely.  It has been six months since I began treatment and I go in for a check-up at the end of the month.  Much of my lower leg is a dull red brown, leathery, stiff, tender and sometimes a little achy.

So, medically, I have had good care.  Really good care, I would say.  What’s the problem?

To get care outside of the VA system there must be an authorization.  This requires a request, confirmation from the physician who will be administering the care, with an authorization number generated.  I had to reapply for these every 3 months at first – because I was being followed by my surgeon and later by the radiation oncologist – and later those got extended in length.  Each time I went for care at Duke they had no record of the authorization with the VA insisted on sending directly to Duke.

So, I would go to Duke, find out they knew nothing, make a call to the Non-VA Care office, get the authorization number and proceed.

Duke and the VA both have web sites where patients can keep records like their weight, blood pressure, blood sugars and the like, find out about services being offered, the results of some tests and studies, and in the VA’s case leave messages for your primary care doctor.

The other day when I logged on to my DukeMyChart site there was a message about reviewing my account.  There was a bill for many tens of thousands of dollars and a place to enter your credit card number.  Alternatively, I could call the Duke billing office.  As it turned out, Duke had not been paid for over a year.  Duke now has an office full of clerks that just work on getting reimbursed by the VA.  Another four of five hours on the line with the Non-VA Care office and the Duke Billing office resulted in the billing office getting authorization numbers for past service.

Today, I got a call from Jeff in patient registration telling me that there is no authorization for my upcoming visit.  My conversation with Will at the VA a few days ago left me with the impression that I am now approved for care until January 27 of 2019.  Jeff was not friendly and was not willing to call anyone.  He wanted me to bring my pape stating that I was authorized. Otherwise, I am responsible for the bill.

 I don’t have that paper.  Theoretically, Duke has it.  One of the billing clerks at Duke told me that the VA sends authorizations that get routed as often as not to the wrong office.  Duke clinics and offices seem to be blind to each other.  When the paper arrives at the wrong office it gets folded into a paper star ship and tossed into the nearest black hole.

Both Duke and the VA are big systems that I believe do a good job of caring for people within their respective systems.  The problems begin and continue, unabated, when one system tries to communicate with the other.

There are problems created by HIPPA.  One institution cannot just call the other one or my privacy might be compromised.  I have to be a middle man.

I don’t know why Duke isn’t getting paid.  They say their requests are being denied.  The VA regional reimbursement office is in Salem, Virginia.  There is no one there that I know to talk with to find out why the bills are being denied; or whether they actually are being denied.

Tomorrow I will be on the phone again.  Imagine what it would be like if I was sick.

Views: 159

Comment by Rodney Roe on May 18, 2017 at 7:54pm

Appointing a Special Council may be just the thing for Republicans who want to move on to bigger things like gutting Obamacare and going back to the good old days when there was a chicken in every pot unless you had to give it to the doctor.

Comment by koshersalaami on May 18, 2017 at 8:01pm

Bureaucracy 101

Comment by Ron Powell on May 19, 2017 at 12:12am

Single payor might not clear up your particular problem.

It means a larger bureaucratic maze to navigate between care giver and bill payor. Buracracy 202.

You probably should try to establish a procedure that allows you to keep recordes of your own.

Sinlge payor won't be of any great consequence until we remove the profit motive from the system and declare health care a fundamental human right. 

Doing that would ensure that caregiver and payor interact properly because the patient would never see a bill.

As it stands now the patient bears the primary responsibilty for payment unless and until some entity acknowledges  and authorizes thae payment. 

You can be certain that lives and limbs have been lost in that "black hole" along with misplaced authorizations...

Re the clerk who wouldn't cooperate.  I know that it's easier said than done, but you should never take 'no' from someone who doesn't have the authority to say 'yes'.

Comment by Rodney Roe on May 19, 2017 at 2:16am

@Ron ~ I guess I can’t envision – or prefer not to imagine – a national simgle payer without a national health service with universal access.  Does developing such a service require legal recognition of the provision of healthcare to be pursuant to a basic human right to healthcare?  Perhaps.  If so, given the present mood in congress, and the resistance to government responsibility for anything but buying weapons to protect American business interests abroad that has been deepening for decades I’m afraid that we will never have it.

The use of the word right, in the same way we use rights such as life and liberty and equal access to things like voting causes a problem in my mind.  Life requires sustenance through food and water, and protection from the elements. The assumption has been that it is government’s responsibility to ensure that no one takes those things from us. It has never been assumed that government’s role is one of providing a home, clothing, an adequate, healthy diet and clean drinking water.

Healthcare as a right would assume that it is government’s role to ensure that everyone has access to a basic level of healthcare, and that would require an admission that to do so required government oversight, at least of such a program and paying for at least some of the population out of taxes.

The best system would not be “Medicare for All”, but Medicare for All with government purchasing and elimination of the profit motive not just for those actually providing services like hospitals, doctors and physical therapists, but also for drug companies, the providers of “durable medical equipment” and any other suppliers of services to the actual providers of care.  That would require a basic shift in thinking about the rights of Americans to “pursue happiness” in the form of pursuing a profit.

The worst system would be Obamacare with a public option and no attempt to control costs.

Those who want to provide something even less than the ACA want to go back to the good old days when 40% of Americans had no access to healthcare short of a visit to the Emergency Room of a hospital.  They see denial of services as the route to controlling costs rather than reducing the fees for service and establishing fair prices for drugs by government purchase of drugs and other items and provision of those drugs to the patient.

I can’t remember how LBJ got congress to swallow the idea of paying for the healthcare of seniors, but it probably had to do with the fact that none of congresses business backers would be denied a profit.  In the beginning everyone got to bill Medicare on a cost plus basis.  The overreach by everyone under that approach looked like that of defense contractors.  It only took about 10 years for the Health Care Financing Administration to come up with the system of billing based on Diagnosis Related Groups (DRGs).  That did nothing to limit the profits of non-care givers, though, and produced the enormous healthcare systems that we see today; systems that have grown larger and more unwieldy in an effort to take advantage of group purchasing power.

I’m afraid that the concept of healthcare as a basic human right, since it will require government’s role being active provision of services rather than a legal system ensuring that no one takes those things away, will require an amendment to the constitution.

The second amendment wording, “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed,” said nothing about government being responsible for supplying those arms.  Perhaps it should have.  Every American would have a musket today.

My point is that the amendments seem to be about no one taking needed things away rather than providing for those needs.

I haven’t run through all of them for an exception. Perhaps you can think of one.  Healthcare as a right would require a major shift in thinking of everyone.

One other thing some of the buzzwords and phrases like “single payer” bring to mind basic assumptions in any one individuals mind that may not be shared by everyone or even anyone else.

Thanks for your thoughtful comment.

Oh, and about the clerk who called.  It was right at five when he called.  I think he was getting ready to turn the light out in his office, so to speak, had a thankless job, and heard blowback from people like me all day long.  He would never be calling if paitients never saw the bills.

Comment by Rodney Roe on May 19, 2017 at 2:24am

BTW, the clip art figure with the dark glasses would flunk "cane 101".

Comment by Rodney Roe on May 19, 2017 at 3:02am

This morning’s edition of The Lancet had the results of a study relating health and morbidity to access to care.  My color vision is poor, but I believe that this image shows the U.S. to be in the 8th decile (10th being best) along with the U.K.  Our neighbors to the north were in the 9th decile.  Iceland was in the 10th.

The full article is here in case you are interested into getting into the weeds about how the study was conducted.

Also, the top figure is for 1990 and the second figure is for 2015.  Did the ACA account for the improvement in the U.S.

I actually thought the U.S. would have scored lower, but for some of the disease mortalities like tuberculosis, which is a big killer worldwide, the determining factors are nutrition and genetic susceptibility more than access to care.

Comment by Terry McKenna on May 19, 2017 at 3:42am

We need single payor, and national regs that mandate maximum fees etc.  Even with "good" private group insurance, there are strange holes in the current system.  For example, you can use an in network hospital and surgeon but receive an out of network bill form the anesthesia.  Ours is a mess.   By the way, the better way to assess the US is not to look at the entire world - where we end up looking pretty good, but by comparing only our peer nations - and there we look like shit.  

Comment by Rodney Roe on May 19, 2017 at 4:13am

Good point, Terry.  It looks like we are on a par with the UK and some of the Eastern European countries, but behind most of Western Europe including Ireland.  It is cold comfort to know that we are doing better than Libya or Haiti.

Comment by JMac1949 Today on May 19, 2017 at 5:51am

I spent a month scheduling consultations with the VA Outpatient Clinic in Austin Texas only to find out that the VA offers no assisted living benefits for my older brother.  The best they could do was $1700 a month for home nursing care and hospice care.  We left the final appointment with a pile of paper an inch thick.  The facility was a relatively new structure with three floors surrounding a lobby about 300 feet long and 60 feet wide.  There was a huge abstract metal sculpture suspended in that empty space, and as we waited to speak to the various bureaucrats/ medical professionals, I wondered how much money was spent on that building and bad art that could've and should've been spent on the staff and medical care of Austin's veterans.  Priorities???

Comment by Steel Breeze on May 19, 2017 at 6:24am

i hearya,when i went to sign up at VA it took 16 months cause i had to get my military records and prove combat statis.i got enrolled after my Agent Orange exam and moved up to level 6 after sendin them a copy of my combat ops.....a hassle,but worth it.also a friend of mine owns a hospice care company and deals mostly with vets,he says the VA always pays up,but he never knows when or how much....one day he gets a check 5grand and the next its 200K.....

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