The Third Third

My Rx for Health Care

I think that ancient Chinese curse has taken hold: we are indeed living in interesting times. These are, in many ways, the times my Dad has worried about his entire adult life. As a child of the Depression, he was always afraid of running out of money. And as a physician, he was terrified of “the government taking over” health care. (Instead, as I have pointed out to him repeatedly and to no avail, the insurance companies took over health care and made a real mess of it.) As the Obama administration takes on both challenges – the economy and health care reform – all the while linking them inextricably, I am feeling a huge sense of bystander’s responsibility. I’m heavily invested in the government getting this right. Yet I’m not sure I have a voice in the discussion, and I know I’m not a player in the game. What’s a bystander to do? I’m ready for the times to be a bit less interesting. Translating this at both the macro and the micro levels, that would mean something like steady 5 to 7 percent growth in the economy (and by extension, the stock market, upon which our retirement depends), and a dependably accessible and effective health care system (and for me and mine, one smart, attentive primary care physician with access to the best resources should we need them). Nothing too complicated, right? But, as the cliché of the week insists, “The devil’s in the details.” (Just as an aside, can one call a trillion dollars a “detail”?) For the moment, let’s leave the economy to the, ah, economists, and move on to health care. Oh, how they’ve muddied the waters. What exactly is health care today? Is it your insurance policy, the one your employer negotiates and you pay for, the one that costs as much as tuition at a public college and gives you your $270 antidepressant for a $50 co-pay, the one that denies coverage for a $1,200 - $2,000 colonoscopy but pays 80 percent of your $55,000 hospital bill when you get colon cancer, and for 100 percent of your chemotherapy, the one that refuses payment for any dermatology, or the one that caused your obstetrician to send you and your newborn home from the hospital a day early it covered so little? Or is it the nearest emergency room, where your doctor sends you at midnight with abdominal pain, or your husband takes you when you fall and cut a deep, three-inch gash in your hand, or where your housekeeper goes, mid-day, when her under-treated diabetes makes her faint and woozy; where you will wait a long time, and she will wait an eternity, surrounded by folks coughing, wheezing and bleeding for whom this is their only care? Or is it the medical school and its network of hospitals, rich in researching specialists, thin on clinical care, that you are just happy to have in town to raise the level of sophistication available? Or is it your friend, the woman who happens to be your gynecologist, who eschews all insurance to practice medicine the way she thinks it should be practiced, and who gives you her home number, her cell number and strict instructions to call her, even if all you need is medicine for a cough or flu, because she knows what a hassle it could be otherwise? Or is it your sister, also a physician, who will, in a pinch, call in a prescription for that pink medicine that gets your kid through an ear infection over the weekend, or a pain pill for your back spasms if they hit on a holiday? Or is it the wellness clinic up the street, the one where, for thousands of (non-insurance) dollars, you can get tests and scans out the wazoo to reassure you on one hand and to remind you, on the other, to eat well and exercise? Or is it the satellite clinic, on the other side of town, to which the poor and the uninsured flock, both with and without appointments, resigned to waiting, to seeing one doctor or nurse practitioner and being given an appointment to see another on a day they have to work in order to pay the rent, to get their pap smears and mammograms, to ask for medicines and to have their symptoms, more often than not, dismissed, to have self-care instructions explained in detail, even in Spanish, yet not understood, culturally at least, as critically essential to their well-being? Health care today is, of course, all of this – and much, much more. The research, the drug trials, the pharmaceutical companies, the universities, the politics, the economics, the physicians, the hospitals, the nurses, the aides, employers, the state, and the federal government. Small wonder a recent poll suggests a bit of confusion: Yes, we need health care reform; but No, don’t mess with what I’ve got that works. Health care erosion over our lifetimes, I would suggest, has taken its toll. So what kind of oar do we stick into these muddied waters, and in which direction do we pull? The arguments both for and against the assorted plans currently in circulation in the House and the Senate and the White House are political and philosophical and selfish and short-sighted and, most of the time, distractions from the job at hand. I have yet to hear any Congressman or Congresswoman describe his or her health care in terms of insurance, access, and quality, much less to suggest that all of us as citizens of the U.S. are entitled to the same. Or, for that matter, to say why we’re not. That would seem to me to be a very practical starting point. And practical is sort of the point here. We need something that works – morally, we need it to work for all Americans and individually, we want it to work for ourselves and our families. It’s like medicine itself: because I grew up in a family of doctors, I showed aptitude for the profession and, at one time, thought I should become one myself. The profession met my criteria – I would be considered smart and I would be of service. Then we got to the nitty-gritty: organic chemistry, blood and guts, and sick and sometimes smelly people. This was not for me. But if the government is going to fight the failure that is health care today, it’s going to have to get down and dirty, get in there with the blood and guts, the good patients and the bad, the good doctors and the bad, the good insurers and the bad, the good players and the bad, and make it work. So what do you consider essential in a reformed health care program? Here’s my list: (1) Understanding of health care as a commodity, like a utility, that, at some point in our lives, we will all have to use, and that we must, therefore, all be able to afford at its most basic level. (Subsidies may be required for those living below a to-be-determined poverty level.) (2) A commitment, on both the personal and societal levels, to preventive care. (Financial incentives may be required.) (3) Insurance, which like life insurance, provides coverage for the unexpected, such that the unexpected does not break anybody’s bank. Well-care and maintenance, we should, as individuals be expected to pay a reasonable price for; high cost prescriptions, surgeries, chronic illnesses, life-threatening illnesses, and debilitating injuries need to be insured -- responsibly, affordably, dependably, and universally. (4) Standardized quality care at the highest level (not the lowest common denominator) as determined by effectiveness outcomes and best practices, and medical professionals continually educated about the same. Establishment of U.S. goals to rank at top of all world health indices by year 2020. (5) Ready access to quality routine care; and prescribed –but equal – access to specialty care. In accordance with medically determined needs, patients should retain freedom to choose – and maintain relationships with – their physicians and other care providers. a. Incentives to train and produce the health care providers required to deliver accessible quality cradle- to-grave health care across the nation; b. A professional pay scale commensurate with the requisite training and experience. (6) The establishment of shared core values regarding children’s health, care of the aging and elderly, responsibility for the disabled, food, drug, worker, and environmental safety, with, at the same time, allowances and/or exceptions for the individual right to pursue (most likely at personal expense) medical measures otherwise deemed extraordinary. Please add your thoughts. And check out the often thoughtful contributions of several other constituencies on the *New York Times*, at: ****.
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