The DSA (Democratic Socialists of America) will be organizing a canvassing effort tomorrow in my neck of the woods to promote and discuss Medicare for All. Because I’ve spent the majority of my time in the workforce in healthcare in some capacity (and because my current state of health – i.e. maelstrom of allergic and viral sinus related carnage – will prevent me from participating), I felt I should at least comment here. Hopefully I’ll have a chance to elaborate on some of this later, but hey – a quick and dirty summary is better than nothing. I’ll start with the obvious stuff everyone knows:
1. It’s the best plan on the table. Even the various other “public option” plans don’t cover everyone, and of course it’s clear what will happen to that public option (even if it’s “Medicare for All Who Want it,” which would be better described as “Medicare for All Who Can Afford It”). It will become just one more thing for the Privatize Everything crowd to deliberately kneecap, then point to as evidence that government doesn’t work, etc. etc. You know, like they’ve been doing to the post office for thirty years.
2. It decouples healthcare from the employment system. This has enormous benefits both to employees and to businesses, as it provides security to the employee and frees the business from its biggest employee benefit expense. Granted, most of those savings will surely be hoovered up by every petty King Croesus out there in capitalism land rather than going into employee compensation, but at least it won’t be going into the pockets of the most useless parasites in the FIRE sector. Healthcare, as we can easily determine by looking to other nations that already have a single payer system, can be effectively delivered without having to produce large profits not for the caregivers, but for the bureaucracy that hands out the coverage. A bureaucracy isn’t supposed to be a revenue generating enterprise – it’s an expense that facilitates production occurring elsewhere. So why, in US healthcare, does the bureaucracy that tracks who receives care need to make such enormous profits? (Because it’s a private for profit business, obviously, but that’s exactly the point – it doesn’t have to be).
3. Everyone else is already doing it, and seeing better health outcomes and lower expenses. Really, how is this not obviously better? I’m going to stop here and move on to the main event, something I haven’t seen mentioned in the healthcare debate.
The field of health information management doesn’t involve the sort of work anyone outside of it would normally find interesting, but one element of it is certainly impacted by the state of the US healthcare system. The World Health Organization produces a medical coding system called the International Classification of Diseases (ICD) which is now in its 10th incarnation (ICD -10, or ICD-10-CM in the US). It is used to transform medical documentation (doctor’s notes and the like) into what might charitably be called an incomprehensible international alphanumeric code for use in research and billing. Well, sometimes billing – not every country that uses the system necessarily uses it for both research and billing – but we do. Of those that do, pretty much everyone else does it differently than we do … because most of them have a single payer system. What does ICD-10-CM do for researchers? Oh, nothing much … it provides a vast database of easily searchable dynamic health information documenting disease processes, patterns of illness, social determinants of health, causes of injury, frequency and nature of treatments, results of treatment and even mental illness, which can be used to identify patterns in disease transmission, comorbidities, complications, and on and on and on … one might, for example, use ICD-10 coded data to investigate any correlation between (let’s just make up a totally random example), opioid dependence, depression and chronic pain occurring together with social determinant of health codes for unemployment, homelessness, and low income. Oh, and because the data is expressed in alphanumeric format, it can be understood in any country that uses the system, even across languages. The research potential is unparalleled, and we’re just scratching the surface of what might be possible. But in the US in particular, there’s a snag – billing. Medical coding in the US is basically directed by the Center for Medicare and Medicaid Services (CMS). They revise, tweak and update ICD-10-CM to reflect new medical research, new treatments, etc. Their decisions also have an impact on billing, as they can change the way or the frequency with which a particular diagnosis or procedure is coded, which in turn can affect how it is reimbursed. The difficulty arises because while CMS can easily keep track of Medicare and Medicaid reimbursement systems, they can’t do the same for the hundreds and hundreds of private health insurer systems out there, systems designed by people who want to avoid paying claims. This creates an industry fraught with hair trigger tensions and incentives to manipulate the way data is processed and attempt to influence revisions in coding and reimbursement systems that may be linked to payment rather than clinical data. In short, just having a for profit health insurance industry arguably creates a conflict of interests in our health information systems. In a single payer system, this isn’t an issue – because there’s no profit motive and only one or two reimbursement systems using the codes, but in our system there are hundreds, and all have an interest in influencing the system for their financial advantage, which might be affecting the accuracy of our coded medical data, which in turn may distort the accuracy of medical and public health research. The ICD coding system is supposed to be used to track data, outcomes and resource allocation. If we want to be sure our medical data is accurate, we need to either decouple coding from billing (likely impossible for us at this point, if we’re paying doctors and hospitals based on what they do), or we need to take the profit motive out of insurance to eliminate the incentives to influence our medical data. It’s not as exciting as other arguments for Medicare for All, but there are plenty of medical coders out there who grind away at their desks, aware that their profession is forced to serve two masters: data integrity and the public good on one side, the medical industrial complex on the other. If we have a chance to deliver health care to everyone as a human right and produce more accurate medical data leading to more useful, more effectively targeted research, shouldn’t we take it?