PERSPECTIVES ON PROPOSITION 186 : What If Health Care Were Run Like the Schools? : Volunteers compensate for poor quality in the classroom, but that’s not an option when this ‘single payer’ slips up.

The bumper sticker I want between now and the November election would say this: “If you like California’s public schools, you’ll love single-payer health insurance.” While the comparison may seem unlikely, as a mother and family physician I can’t ignore some obvious parallels between public schools and state-run health care.

Those who would redesign health care should take a lesson from the single-payer education system that continues to spiral downward. That California’s public schools, by almost any criteria, fall into the bottom-10 category when compared with those in the other 49 states should be a lesson regarding the proposal to surrender monetary management of health care to the same economic handlers. The forces that impact public education--budget shortfalls, a large welfare-dependent population, political maneuvering and bureaucratic inefficiency--are the same that would affect a single-payer health-care system.

Administrative costs is one area that bears financial comparison. The proponents of Proposition 186 would have voters believe that only 4% of the total cost of the program would go toward administrative expenses. Does this mean that 4% of the budget would be spent contracting out the coverage to private companies, which would then add their own administrative costs? Or is 4% the total administrative amount? Medi-Cal, one example of a state-run program, doesn’t operate with the administrative thrift to which Proposition 186 aspires. But if other government-run medical programs aren’t sufficiently direct comparisons, perhaps examining the gap between the high administrative costs of public schools and the predictably lower administrative costs of privately run schools would be instructive.

Another troubling financial issue pertinent to the discussion of single-payer education as it applies to single-payer health care has to do with why the same dollar amount--$5,200 per student was the number widely accepted during the voucher debate--buys so much less in the hands of public educators than private ones. It’s tempting to surmise that inefficiency is a congenital defect of government-run (read single-payer) organizations.

Beside the financial reallocations being sought, Proposition 186 would require substantial shifts in the way we think about medicine and who provides it. The slowdowns and strikes that plague public schools as a result of teacher demands vs. administrative dictates should be a forecast of what we’re in for when health-care providers become labor and the state, management. Or, are we to expect that health-care providers march to a more altruistic beat than do the teachers to whom we entrust our children each day?

Proposition 186 provides for a new health commissioner to oversee the budget and operations of the program in much the same way that the state manages the public-education system, from the top down. The impersonal decisions made at the top have had devastating implications in the classroom. In public schools, overcrowded classrooms and staff cutbacks are addressed by recruiting parent-volunteers. This solution has obvious limitations in health care.

Finally, quality is an issue. Parents who have never had a child in a private school are often content with their child’s public education--especially parents of gifted students, who get more personal attention. If, however, you talk to parents who have transferred a child from private to public school, they tend to be unhappy (unless the switch is to one of the rare public schools whose location and socioeconomic constituency make it possible to operate like a private school). The complaint is that public schools are not as consumer-responsive.

In the case of health care, Proposition 186 would take California from a private to a public system, a switch that for most consumers is not likely to engender contentment. Faced with the shortcomings of public education, many parents tolerate the situation by augmenting their children’s education at home. This option doesn’t exist in health care.

The obvious and fatal flaw of single payer is its preservation of the costly open, unlimited and unquestioned access to specialty care. Many doctors have become skilled at thwarting the price-per-visit caps on their Medicare patients by encouraging more frequent, if unnecessary, visits. Where there is completely open access, there will be ways for providers to exact payment, whether from insurance companies or a state agency. This fact is taking its toll on the system in Canada. The experience of existing single-payer programs should make the specter of Proposition 186 worrisome to anyone living in California.