I haven't yet taken the
opportunity this year to render my thoughts on U.S. health care and how it
should be funded and implemented.
President Obama's plan for health care has come before the U.S. Supreme
Court and its fate has already been decided.
We are waiting for the clerks of the Justices to write their opinions. The Republicans maintain, in a strange twist
of logic, that people demand the right not to buy health insurance. With some exceptions of extremists, who would
actually choose not to have health insurance if they could afford it? The Republicans will next argue that people
have the right to be poor and that we shouldn't take that right away from them!
My mother was leaning
toward the Republican argument until I asked her what she would have me do if
someone entered the emergency room in the midst of a potentially lethal heart
attack without health insurance. Should
I save his life even if he doesn't have insurance? I asked. Of course, she answered.
"There's the rub," I
responded. "Once you believe that we as
a society have the duty to save people's lives when they are having
health
crises for which they cannot pay, then we need a way to pay for it.
That's what we have now. The nation's hospitals provide a somewhat
dysfunctional local health insurance by virtue of laws preventing them from
turning people away at the emergency room door.
Hospitals in New Hampshire have sued their state government because they
are going broke from this policy arising from laws forcing them to provide care
without any means of remuneration. It's
also important to remember that when those who have not had health insurance
come to the emergency department, their bills are usually larger than those who
have had care, because more has gone wrong.
I found the interstate
commerce debate confusing. It seemed
simple to me that we must care for whoever comes to our door regardless of
where they live. For example, our
hospital in Brattleboro is the closest hospital for people who live in Hinsdale,
New Hampshire. If they have an emergency,
the ambulance is going to bring them to Vermont regardless of any other
concerns. Our hospital is three minutes
from downtown Hinsdale, while the closest New Hampshire hospital is 35 minutes
away in Keene. I'm not sure how well New
Hampshire insurance pays our hospital, but I know that we do not accept New
Hampshire Medicaid for psychiatric services since it pays $23 per hour visit (less
for shorter visits). That compares to
Vermont Medicaid which pays $87 for a one hour visit. State lines don't appear to exist when it
comes to medical emergencies and hospitalizations; only for routine visits. The New Hampshire to Vermont transfer works
in reverse when we have really sick people in our hospital. The closest major medical center is at
Dartmouth University, which is in Lebanon, New Hampshire. They send a helicopter to pick up our really sick
people and bring them to the academic medical center for the advanced
technology they have there. Apparently
state lines don't matter there either, for we don't send people the 260 km to
Burlington, Vermont, to the University of Vermont medical center just because
it's in-state.
The proposal which makes
the most sense to me is that of Senator Bernie Sanders of Vermont, who believes
that local regions should control their own health care budget. I think this could work in Vermont because we
could decide where the money is best used in accordance with our local values
and practices. We might choose to cover
supplements and fish oil and not the most expensive drugs in the pharmacopeia. We might add massage therapy for people with
chronic pain and perhaps stop paying for anesthesia blocks since these do not
appear to be better than placebo. We
might change every six months as data and preferences change, but we could do
that.
I do think everyone needs
health care coverage. We need to know
that we are covered in the event of illness or accident. Someone must
pay for this coverage. It must come from health care insurance
premiums paid by people or from tax funds also paid by people. Either
way, people must pay for health care,
either through taxes or through premiums.
I would prefer taxes over premiums, but that is my personal
feeling. I would prefer a decentralized
system in which each locality has a health authority which is populated
by a
community board of directors who determines how our portion of the
health care
tax is going to be spent in our community.
We could struggle together to make the hard decisions about
allocation. We could engage in the
dialogic process as we do that. It
wouldn't be perfect, but no perfect decision making system exists.
Plus if we had the money locally, we would be
forced to think locally about our neighbors and friends and not abstract
concepts.
In my experience, what no
one wants to address is the escalating costs of health care and why they are
not going to stop rising. Health care is
only getting more expensive and will continue to become progressively, even
exponentially, more expensive as time progresses. New technology costs money and everyone wants
more technology (seemingly). New drugs
cost more than old drugs, and everyone seemingly wants new drugs (though few
new drugs work much better than old drugs).
When we invent a new test, we rarely stop performing the old test that
the new test was meant to supplant.
Usually we do both tests.
The medicalization of
life has generated tremendous costs for health care. Ordinary misery has been elevated to a
pathological condition. Every ache or
pain demands a label and a diagnosis. In
my role as family doctor, people bring to me a myriad of symptoms in search of
diagnosis. Most of these symptoms will
defy diagnosis unless I can convince them that their symptoms are part of
life. Life involves aches and
pains. Life involves some element of
suffering. We get tense. We get uncomfortable. We forget how to relax. We get anxious and experience the somatic
symptoms of anxiety. Our lifestyle leads
us to pro-inflammatory conditions. This
irritates our joints, causes our immune system to produce pro-inflammatory
cytokines which makes us feel flu-like, makes us feel depressed and more
anxious, and promotes the development of other chronic medical conditions. This pro-inflammatory syndrome is just being
recognized and has no real pharmaceutical treatment. Its solution is to sleep more, to exercise
more, to eat an anti-inflammatory diet, to have more fun with other people, to
stretch more, and the like. So much of
family medicine is about moving people in common sense directions to reduce
inflammation which will improve their symptoms.
Laboratory studies don't really help me to do that, but are what
patients often want.
Chronic pain represents
another example from my area of practice.
Countless thousands of dollars are spent on X-rays, MRI's, and CT scans
of the areas of pain. They are really
revealing. Studies have shown that the
findings of these studies rarely correlate with levels of pain. They "hypnotize" an entire population of
patients to believe that they are hopelessly immured in chronic pain with no
hope of recovery, when that is not necessarily the case. Often, the same simple measures will work
wonders with chronic pain and cost very little.
Similarly, coaching people to lose weight and to exercise costs
relatively little compared to the costs of being obese and not exercising, yet
current health insurance does not cover these costs. If we had local control over our health care
dollars, we could make decisions about these types of matters on the local
level and spend our money as we believe would benefit us best. That's my recommendation for health care --
use tax dollars, cover everyone, give the money to the smallest local entity
possible (village, township, shire, etc.), let the local entity decide how to
spend it, and struggle with our unrealistic expectations of contemporary health
care.
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