The advocates for comprehensive health care in New Hampshire (Monitor front page, Jan. 13) are certainly on the right track; the evidence is overwhelmingly conclusive that single-payer care plans increase health and wellness in populations enrolled in them.

Having said that, the plan as envisioned by the New Hampshire Cure Act is entirely non-executable.

– We could never afford it: The population and wealth distribution of New Hampshire alone will not begin to support the plan as presented in the article.

– We don’t have a plan: There is woefully inadequate experience or resources at the state level to do the necessary research and groundwork to establish a single-payer plan.

– The plan as outlined in the article describes a system where the patient has no skin in the game, no incentive to engage and take accountability for their own care. Things like co-pays and deductibles are key in driving this. A modest, income-scaled premium scheme not only drives accountability, but is the right thing to do – those who can afford it should subsidize those who need help in a self-sustaining system. The Medicare experience serves as a model from which to learn.

– Operationally most important, a single-payer plan has to have standard processes (often called clinical pathways) used by all to provide care, to make decisions, maximize outcomes and coincidentally control costs. Industry calls this “standard work” – a proven methodology to increase quality at the best cost. These do not exist in health care on a national level and are well beyond the resources of a single state to develop, or adapt.

– Lastly, a state plan in the midst of an incompatible national health care business model simply will not work. The changes in priorities of a single-payer plan are fundamentally at odds with what drives the capitalistic system from which ultimately the state must acquire care and services. In no way is this a goal not worth pursuing, but it is a national issue. One need only look at the premier directly congressionally-supported federal programs to see the challenges and cost this presents: Medicare, the Military Health System and the VA.

The claim that the United States has developed the best health care in the world, as quoted in the article, is patently misleading, as it only partially defines “best.” The definition of “best” is crucial.

Simply put, there are two measures of health care: technical competence and outcome. Technical competence looks at the medical advances – procedures, treatment and drugs, without real regard for access. Superb care does not exist for those who cannot get it.

Outcomes look at relative health of populations and include all aspects of a health care system (technical competence, access, patient engagement in self-care, as examples). We are indeed among the world leaders in the former (technical competence). But in the latter (outcome, i.e. health), pardon me, we positively suck.

Let’s look at some data:

– According to the World Health Organization, the United States is 38th in recognized and standardized population health outcomes in the developed world. It would shock one to see some of the countries that whip us. And we are twice as expensive as the average of all other nations in cost.

– Our obesity rate is, sadly, world leading: 160 million (more than 50 percent) of Americans are overweight, 78 million of these are obese (more than 26 percent of us). These are conservative figures. To compare, China and India, with their vastly larger populations, weigh in at 46 million, and 30 million respectively. It must be noted that obesity is directly related to development of heart disease, cancer and diabetes – diseases that are killing us literally and in cost of health care, and projected to “break the bank” in the future. (Anything Congress does to Medicare will pale by comparison).

– The cornerstone of health is primary care, and prevention aimed at reducing the above, and we lack at least 25,000 primary care providers. And we do not have a national strategy to fix this.

– We have millions of underinsured or uninsured Americans who do not get care until severely ill, presenting in a tertiary care setting, where options and outcomes are limited – in effect after we have lost the battle for health. I cannot resist an editorial comment: In a capitalistic health care system, where profits drive behavior, use of high-tech/high-end care is an incentive. High-end care and pharmaceuticals make a lot more money than primary care and prevention, which done well paradoxically decrease future profits. Talk about a tough nut to crack. Capitalism is very hard to reconcile with the concept of health, which by its very nature reduces demand for services/products.

We have developed the best interventive care on the planet to compensate for the poor job we are doing to prevent the need. If the outcome we are looking for is health and well-being, we are talking about decreasing the amount of disease as a primary strategy, and needing less tertiary care for those with whom we fail.

We are talking health care strategy, which demands the use of recognized health outcomes when we try to rate or measure it. But hopefully by now I have painted the picture that a single-payer (universal care) approach promotes health, while the capitalistic approach promotes high-tech development, and profit but not necessarily health as defined by currently accepted measures. It certainly increases costs.

It must be noted here that the huge advances we have made against nonpreventable diseases (such as the neurologic and immune-related diseases as examples) are independent of this argument – care for these begins at the high-tech interventive level. And we are among the best. But this requires huge capital – and paying for it will be an issue that has to be addressed in development of a single-payer system.

We cannot lose sight, however, that to change health care there will be costs, some borne over the long haul by high-end providers and Big Pharma as disease rates fall in the future. This is very real, and a strong incentive to maintain status quo.

Anyone embarking on a single-payer system will have to dedicate additional resources to primary care up front while maintaining the interventive high-end care until disease rates decrease – while maintaining our edge in technologic breakthrough, and care for nonpreventive disease. It is not a matter of a simple shifting of resources – it literally is a basic conflict between health care models with different incentives and outcomes.

We have to decide how to reconcile these, and begin leveraging our vast capability to provide health opportunity to all, while holding each of us accountable as consumers for our part in our own health (we are lousy at this, by the way). Clearly this is not a state-level endeavor. It requires a national effort, against headwinds of special interests and corporate profits, as well as the Herculean task of defining health and the processes required to achieve and measure it. It occurs to one that the slashing of corporate taxes may give us a brief window to begin the required investment up front.

(Jon Pearse is a retired Air Force family physician. He lives in Concord.)