This leading Boise physician says it’s time to go to single-payer health insurance


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Dr. Ted Epperly is one of five experts the Idaho Statesmanís Business Insider magazine asked to describe how to repair our broken health-insurance system.

Ted Epperly literally wrote the book ó well, a book ó on how to fix Americaís health care system.

So the leader of Family Medicine Residency of Idaho didnít have to think long when Business Insider asked what his ideal American health system would look like.

First, some background: Epperly is an Idaho native and a retired Army physician. Now, as CEO of FMRI, he runs a training ground for primary care physicians that attracts medical graduates from around the country.

FMRI also is a Boise-based network of eight health clinics with 30,000 patients ó most of whom are on Medicaid or Medicare or are uninsured. All patients are accepted, with a sliding-scale payment.

Itís safe to say that Epperly and his residents see firsthand, several times a day, the tragedies and struggles that arise when a large segment of society goes without regular access to health care.

ďIf I could wave a magic wand, it would be: Letís focus on basic principles. First, health care is a basic human right,Ē he says. ďLetís integrate and coordinate around that. Letís make health care accessible. Letís ... start to focus on keeping people healthy, not on treating them when theyíre sick. Thatís a huge, huge distinction.Ē

Here are his comments from an interview:

1. Letís agree: Basic health care is a right

If we could just norm on a couple of basic principles as a nation, it would help us move further down the road. The first of those is, is health care a basic human right or not?

Iím in the camp that it is, in the same sense that K-12 education is. If both of those things are given, every citizen will maximize their potential. You cannot grow up to be successful without a basic education or being basically healthy. If youíre fighting asthma or diabetes or cancer as a kid, itís tough for you to obtain your potential.

That creates a huge political divide.

When you get outside this country, when you take a look at what the other industrialized countries have done ó be it in Europe or be it Japan or Australia or New Zealand ó theyíve done that. Theyíve built that principle around, ďLetís integrate this. Itís not about generating gobs of money. Letís work on keeping people healthy.Ē

I wish that was the state of the industry in the United States. Itís not. And itís not, because of how much money can be generated from health care.

Iím a positive, optimistic sort of guy, always have been, but this is about wealth generation, not health creation.

If that [health creation] was our basic principle, we would do things in a different way. We wouldnít have huge hospitals with waterfalls and pianos in the [entryway]. We would have community-facing ambulatory clinics that guaranteed timely access to keep your diabetes under control, your asthma under control, whatever.

From time to time, people need to be in hospitals. But it shouldnít be the fault of not having a good, basic, functioning primary care system.

2. Re-engineer our workforce

Weíve got a distorted workforce. We need a whole lot more primary care people.

Primary care deals with the whole patient ó from what their job is, to what their health care issues are, broadly focused, not just specifically targeted to an organ system. Is there domestic violence going on? Are there hunger issues? Is there transportation issues that are creating problems? Itís that global knowledge of the individual that helps.

If youíve been coming to me for 15 years and Iíve delivered two of your kids, you trust me. The relationship we would have, it would help me start to dial in on your diabetes.

If you have no relationship with someone that can help you with this, good luck being accountable.

Iíve had many patients who have been very hard to work with. But through the relationship Iíve developed with them, Iíve been able ó because they trust me ó to then start to make an impact on their diabetes.

3. Everyone insured, everyone has a Ďusual sourceí

The Commonwealth Fund found that two things, and two things only, drove better health in a society. No. 1 is some sort of insurance coverage. No. 2 is a usual source of care.

If you have a usual source of care, you know who your doctor is. You know who to call, what clinic, if youíve got a problem.

If you develop a relationship with that person, you donít have to come in every time. You can email me, you can text me, or a telephone call. I would say that 50 percent of my patients, I deal with like that. They donít need to come see me. I donít charge them for that. And I can tell you, that keeps them healthier.

The way our system works is weíre a totally inverted pyramid, where weíve got hospitals everywhere, and very few primary care practices to keep people away from needing to be [in the hospital] for a minor problem.

4. Use money to reward health ó for providers and patients

The way payment works in health care, you get paid to see people ó fee-for-service ó and you get paid to do things to people. So the incentive isnít prevention-driven.

If we can take the payment away from fee-for-service, shift it so itís per-member-per-month with quality incentives ó some shared savings for keeping people healthy so they donít need to go to the hospitals ó all of that results in your better health.

When you go back to D.C., the lobby around health care, the lobby around pharmaceutical interests, the lobby around medical device manufacturers, the lobby around health insurance companies is unbelievable. And what that is all about is preservation of the status quo.

Follow the money. Itís much more lucrative to be a subspecialist. Itís much more lucrative to work in hospitals than in clinics. So weíve got the workforce following the dollars.

What happens in societies, and happens right here in Boise, is youíve got the haves and the have-nots. The ďhavesĒ have places to go and can get whatever they want, whenever they want. And youíve got a lot more of the people who canít. So it leads to distorted health outcomes.

The reason the U.S. ranks 37th in the world ó if you look it up in the World Health Organization directory, right behind Costa Rica ó is because youíve got the rich that can get everything and actually overutilize, and youíve got the poor that get nothing.

I think one of the most underutilized resources in health care is the patient themselves.

Letís incentivize patients for good behavior.

And in fact, letís penalize them as well for poor behavior. Meaning: higher premiums.

If youíre gonna be a smoker ó and God bless you, thatís your choice ó youíre going to pay a higher premium. But if youíre a nonsmoker, you showed weight reduction, you showed 10,000 steps a day on your pedometer, you ought to be incentivized for that.

I think your payment should drop. Just like payment alignment should incentivize what weíre trying to get out of the health care system, I think we should do the same for patients. They should have skin in the game.

5. Scrap the model

Probably the best models for us would be the United Kingdom and Canada.

Now, that starts to become political. A lot of people will they say, ďThose systems are government-run, health care is now becoming communistic or socialistic, and we donít want government interfering with health care.Ē Thatís been the basic drumbeat to keep this at bay.

If it was left to me and I could wave my wand, I would have a single-payer system ó in the sense of the government paying, but still having a pluralistic delivery system. All of the physicians wouldnít necessarily be government employees.

I think that is eventually what will happen. Weíve proven that old adage Winston Churchill once said: ďAmerica will always do the right thing after it tries every other option.Ē

The market will not sort this out, because the incentives are wrong. The free market for health care is to make money. You donít make money if people are healthy. You make it when theyíre sick.

The model needs to be scrapped.

Audrey Dutton: 208-377-6448, @audreydutton

The views of all five experts will appear Sept. 20 in the print edition of Business Insider. Follow these links to the other four:

Lori Shandro OŁten, a Boise insurance broker, says health insurance should be taken off employers' backs.

Dean Cameron, director of the Idaho Department of Insurance, urges a return to pre-Obamacare plans and less federal regulation.

Charlene Maher, CEO of Blue Cross of Idaho, contends that regulation by Idaho instead of the federal government would solve health insurance woes.

John Rusche, a Democratic former state legislator, former insurance executive and a retired physician, argues that everyone must participate in health insurance, and insurers deserve more certainty.

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