Samir Banoob has been a consultant on health care in 48 countries. He's a consultant to the World Health Organization, the U.S. government and several other agencies.
So when he says the American health-care system is the worst in the Western world, he should be listened to.
Banoob, 54, a professor of health policy at the University of South Florida College of Public Health, would like nothing better than to see Americans reform the health system. But he doesn't think much of the plan offered last week by President Bush.
"It was a face-saver, an election-year proposal," Banoob said. "The people who understand health insurance feel this was never a serious proposal, nor that it can solve anything. It is just a political reaction."
Bush's plan depends on tax credits and tax deductions to encourage people without insurance to buy some. He says this will pretty much take care of the uninsured, at a cost of $35-billion a year.
If he's right, that amounts to $140 a year from every adult and child in the country, in addition to the $3,500 per family we're already paying for premiums and the $800 per person we're paying out of pocket.
This rewards the same industry that has thumbed its nose at applicants who have ever been sick and has dropped people from its rolls as they lay dying, delivering them to collection agents.
"This proposal definitely pleases the insurance companies," said Banoob. "Bush, I think, does not care about the health of the people."
The president's plan could easily make the nation's health problems even more serious, he said: "It is very self-defeating."
Jay Wolfson, director of the Florida Public Health Information Center at USF, refuses to dignify Bush's remarks as a "program."
"I think it's wonderful that our leaders at least are giving lip service to the need for health care," he said, "but giving lip service and doing something are two different things."
Likewise, Sister Margaret Freeman of St. Petersburg's Free Clinic has little use for the president's plan. She said it would take an already complicated system and make it worse.
"It sounds like a very cumbersome, involved bureaucratic process," she said.
Bush would offer tax deductions to low- and middle-income people who buy health insurance, and much of the money for that would come out of Medicare and Medicaid.
Sister Margaret calls that "robbing Peter to pay Paul." Wolfson says it will likely put an end to many innovative programs that emphasize health education and preventive medicine _ those not already killed by the budget crunch.
Banoob said tax credits and deductions won't work because low-income people often don't file tax returns and won't have the money up-front to pay for insurance. Also, he said, any raid on Medicare and Medicaid will make the burden even worse on those who have commercial insurance because of what is called the "cost-shift."
When a government program pays discount rates, health-care providers have to charge everyone else more. Banoob says Medicare now pays 91 percent of the cost of hospital care for the elderly and disabled, while Medicaid picks up just 71 percent of the cost of care for poor people. Everyone else makes up the difference by being charged 128 percent of the cost.
Until everyone is paying the same rates, costs will keep spiraling up. And the number of people who can't afford insurance _ now 35-million _ will too.
"We will remain in the same ballgame of having the insured paying the bad debts of the uninsured," said Banoob. "The only way to control the costs is to have one system of negotiated payments."
In other words, national health insurance.
Bush's denunciation of national health insurance proposals as "socialized medicine" is just ridiculous, Banoob said. For one thing, he said, most of the countries that have national health insurance aren't socialist (Australia, France, etc.).
Doctors in most countries with national health insurance work for themselves. For patients, Banoob said, there is at least as much freedom as here because in other countries they can choose their own doctors and hospitals.
Here, 75-million Americans have a limited choice of doctor and hospital because they are on managed-care plans that tell them where they may go. And Bush wants to see virtually everyone in such a plan.
In Europe, patients aren't kicked out of their hospital beds before they're well as they are here, Banoob said. And doctors and hospitals in other countries are not monitored and nitpicked to death by bureaucrats from government and insurance countries as they are here.
A national health program doesn't need to be run by the government, Banoob said, as long as its primary concern is people's health rather than for-profit medicine. In fact, Banoob said, some of the most successful national health-insurance systems in the world use private organizations to set rates and deliver care.
In two recent editions of the Florida Public Health Journal, Banoob makes a devastating case that America's health system really isn't as good as those of Japan, Australia, Canada and the countries of Western Europe.
"America stands alone among these countries by paying the highest costs, using the least volume of regular medical care services, and the highest volume of sophisticated surgical procedures," he wrote. "At the same time it enjoys only an average or below average health status."
Banoob has designed a national health-insurance plan that plucks the best features of plans of several countries _ like Germany, Switzerland, France _ and adapts them to the needs of Americans. His plan, which he calls "Health for All Americans," has the following features:
Coverage. Everyone would be covered for all medical services _ doctors' visits, emergency care, hospital stays, nursing home care, home health services _ and partly for dental care, prescription drugs and medical supplies.
Deductibles would be a thing of the past. Any co-payments would be nominal, and would not apply to prenatal visits, children's checkups and other preventive-care services.
Financing. Each state would have its own independent health insurance fund, and all the money now being spent on health care by federal and state governments, employers and employees would go into it. Those who are self-employed would pay premiums, too.
Delivery. Private organizations could compete for contracts with the state fund to provide health services. They would be set up as HMOs (health maintenance organizations, or prepaid health plans). You could choose among several HMOs.
Doctors could work for the plans, contract with them for certain services, or remain outside the system entirely.
Employers who wanted to offer a fancier plan could do so. And whenever patients enrolled in the state-contracted HMO plans wanted to opt out to see a different doctor, they could, but would have to pay part of the bill themselves.
Management. The state fund would be an independent agency, not run by the government. Its board would be made up primarily of ordinary people elected from the community, with a sprinkling of health-care providers and government officials.
The board would monitor the quality of the HMO plans and would set a fee schedule to partly reimburse patients who wanted to use private hospitals and doctors.
One of the biggest differences between Banoob's proposal and Bush's is that the president's sounds as though it was written by a lobbyist for the health-insurance industry. In fact, it was.
What really steamed Banoob last week was a comment by Dr. Louis Sullivan, secretary of Health and Human Services, that a government insurance system would combine "the compassion of the IRS and the efficiency of the Post Office."
"Why don't they use a successful model, like Desert Storm?" Banoob wondered.
Or they could try the truth _ that the administrative costs in Medicare are far lower than in private insurance, which is efficient only at finding reasons not to pay.
Bush had better watch what he says about "socialized medicine." After all, nearly half of insured Americans are covered by the government already (state and federal employees, active-duty and retired military, Medicare and Medicaid).
Come to think of it, Bush himself is covered by government insurance.
Banoob's health-reform plan
USF professor Samir Banoob's health-reform plan would:
Cover everyone for doctor's visits, hospital and nursing home care, and home health, with no co-payment for preventive services.
Patients could choose from among several health plans or go outside the plans if they wanted to pay some of the bill. Doctors could work for the plans or remain on their own.
People elected from the community would form a board to choose the health plans to be offered. The boards would monitor quality of care.
All the money now spent for health care by government agencies, employers and individuals would be turned over to the board.