Sunday, July 19, 2009

4 Question Interview with Jonathan Kotch

This is the second in my series of '4 question interviews', today with Dr. Jonathan Kotch,MD Professor in the UNC School of Public Health and an active member of Physicians for a National Health Plan, which advocates for a single payer health system in the United States. Like all 4 question interviews, it is published in full.

Question 1. What is the biggest problem facing the U.S. health care system?

The biggest problem facing the U.S. health care system is that it is immoral. It violates a national and international consensus that health care should be a human right. International agreements such as the U.N. Declaration of Human Rights (1948) and the Alma Ata Declaration of the W.H.O. (1978) clearly articulate that health care is a right, and recent polls in both the U.S. and N.C. have documented that a majority of those polled agree.

One can argue whether We the People intended to include health promotion when the U.S. Constitution was established in order to “Promote the general welfare”, but there is no doubt that, in 1789 or 2009, society cannot enjoy a sense of general welfare if its members are not healthy. The fact of the matter is, compared to other western developed nations and some middle income nations as well, the general health of the people of the U.S. is poor. Part of the reason for this problem is that the indigent, the sick, and minorities are systematically excluded from early access to the health care that more privileged members of our society enjoy. Instead of need for care being the principle criterion for allocation of health care resources, ability to pay is the criterion. This is immoral.

As a consequence, poor people are trapped in poverty by illness, minorities are discriminated against in health care institutions, and many children cannot benefit from the right to a free and appropriate public education because of illness, pain, disability, or sensory problems. The majority of such problems, dental caries, speech and language difficulties, or hearing or vision impairment for example, are fully preventable or if not, treatable, if one is lucky enough to be born into a family with money and access to health care. Increasingly, poor and minority children are not, and as a direct result of social inequalities exacerbated by our unjust health care system, health disparities persist.

An unjust and inequitable health care system harms us all. For too long Americans have been seduced by commercial health care institutions, private insurance companies and politicians into believing that U.S. health care is the best in the world. It isn’t. The W.H.O. ranks the U.S. health care system 37th in the world in overall quality. It is mainly the cost and access issues that bring our ratings down, but it is also the case that life expectancy and infant mortality are worse in the U.S. than in every other developed country and some not so developed countries.

Yet, the U.S. spends more money on health care, both total and per capita, than any other country in the world. Where is it all going? In the first place, up to 30 cents of every health care premium dollar goes to pay the administrative costs of running a private, for-profit health insurance system. It has been estimated that, if the administrative cost of providing health care for all were the same as that of providing health care for Medicare beneficiaries (about 3%), there would be enough money saved to provide health care services to every one of the 46 million uninsured persons in our country. In my mind, this mis-appropriation of health care resources is immoral.

Other evidence that the U.S. health care system is immoral is over-spending on unnecessary health care when people are dying (18,000 per year) because they do not have health insurance. In the U.S., one only has to have money to have any amount of health care one desires. There is no limit on how many Botox treatments or tummy tucks one can have if one can pay for them. More serious is the overuse of medical technology. Appropriately utilized, advanced medical interventions can save lives. But in fact, too many patients demand services that they don’t need (whole body scans being a recent example), and too many doctors order too many tests and prescribe too many medications. And those medications, by the way, are more expensive than the identical medications in those developed countries around the world (and immediately to our north) where governments purchase them in bulk and at a great discount, which savings is passed on to consumers.

In a just world, resources for human services would be directed to where they are most needed. In the U.S., the opposite is true. Health insurance companies systematically exclude those most in need, reward their employees for denying claims, drop those with catastrophic expenses, and continue to return enormous profits to investors. If that isn’t immoral, then I have a kidney for sale.

Question 2. What do you most want to see preserved about the U.S. health care system?

What is best about the U.S. health care system is the patient-provider relationship. I deliberately use the term provider rather than doctor because of the importance of a patient’s relationship with many different kinds of health professionals. In fact this privileged relationship has been undermined by the demands of private, for-profit insurers and health care institutions. Doctors and other providers are increasingly practicing medicine in a toxic economic environment, forcing them to make decisions based on what generates reimbursement rather than what generates good health.

There is no way to restore trust to the system as long as Wall Street (and Congress) consider health care to be a commodity. Americans like their doctors, and the principle that patients should be able to pick their primary care provider (doctor or mid-level provider such as a nurse practitioner or physician assistant) is a necessary feature of any health care reform proposal. The imposition of arbitrary distinctions between “in-network” and “out-of-network” providers by profit-driven insurers increasingly violates this principle.

Question 3. What is the most important health policy priority for North Carolina (or the USA)? [answer which ever you want to answer]

For me, the answer is the same for both the U.S. and N.C., elimination of health disparities. The unfairness of continuing barriers to health care, and continuing differences in health status, based on race, income and ethnicity is appalling. The fact that these disadvantaged populations suffer disproportionately from illness, injury and disability is not new. What is increasingly clear is the discrimination experienced by such patients whose access to care compared to white patients is compromised, even controlling for the type and severity of their health problems. Eliminating disparities should be a first principle of any health care reform proposal.

Question 4. If you could design a health system from scratch, what

would it look like?

In this regard I would refer to Health Care for All NC’s “Guidelines for Real Health Care Reform” at Although crafted as a single payer solution for North Carolina’s health care crisis, in fact it borrows some ideas from the U.S. National Health Care Act (HR 676) that is under consideration in the U.S. House of Representatives.

Among the principles articulated in “Guidelines” (see for the entire thing) are:

· Access to appropriate health care is a right. It isn’t something you have to sign up for, and no one would need to be forced to join or penalized for refusing to join.

· Benefits would include all outpatient and inpatient services deemed necessary and appropriate by a Public Commission, answerable to voters, in consideration of available evidence and professional standards of practice.

· The system would be financed by a progressive system of income and payroll taxes, with the result that small businesses would pay proportionately less that large businesses, and low income individuals would pay proportionately less than the wealthy.

· All current providers, solo and group, private and public, would be eligible to participate, provided that they are not-for-profit. Patients would have free choice of their primary health care provider.

· Providers would be compensated based on a fee schedule negotiated between the Commission and their professional associations.

· The system would reward primary and preventive care and eliminate incentives for specialty and tertiary care. Access to specialty care would be by referral only.

· Similarly, outpatient care would be encouraged, and inpatient care discouraged. Hospitals and other institutional providers would be given an annual budget within which they would be required to operate.

· Quality would be assured by the appointment of a Quality Board to monitor the delivery of health care services. The Board would assure that care is available to all regardless of age, race, ethnicity, income or geographical location.


  1. We have a tendency in America to argue for or against a concept based on our own personal philosophy or view of the world, what advances our personal interests, or the interests of our party, family, organization, or region. Perhaps viewing the issue from a management or systemic perspective might result in innovative approaches to the issue. The American national mindset, citizen philosophy, lack of citizen motivation to be proactively healthy, and governance model make the socialization of health care in America very problematic, particularly at this point in time. A country needs to know its limitations.

  2. I often tell my students that I think one day we will get universal coverage...but that it will come about behind Republicans making the business/management case. I hope I am wrong and we do it now....or maybe they will start making this case now a compromise will emerge.