The Steussy Ranch

On Monday, August 24, I engaged in a debate on health care reform at a Town Hall meeting sponsored by the Vandeventer Group.  The audience, though civil, was often hostile, and intimidated me into silence on a few occasions.  When it was over I ended up feeling that I’d left things unsaid, which I’d like to clarify now.

First I’d like to address the general crowd mutterings about the Democratic plan for a Public Option being socialism.  Socialism is defined as government ownership of the means of production, and public health insurance doesn’t meet that criterion.  In the proposed plan, medical care will remain privatized, and government will offer one option, among other private options, to insure people within that private system of medicine.  Beyond that, we’ve certainly had various similar programs over the years – Social Security, Medicare – always criticized for being socialist at the time, and later enjoyed by all as time passes.  Lots of patients have complained to me over the years about their private insurance companies; none have ever complained about Medicare.  Is it deep in the red?  Yes.  Does it need reform?  Yes.  Same with Social Security.  But both provide a critical safety net for millions of Americans.  So, too, would a Public Option health program.

And would anybody call our public school system socialist?  Inefficient sometimes, not always well run.  But everyone reading this has taken advantage of a public school education that somebody else paid for – some previous taxpayers – and now we all pay that debt forward by sharing the burden of the next generation’s education.  We’ve provided mandatory public school education to all children at taxpayer expense (plus private school expense, if the parents can afford it) for well over a century, because we value an educated populace.  It’s time we started valuing a healthy one just as much.

I am not, as some audience members seemed to accuse me of being, a socialist.  Capitalism is a wonderful engine for creativity and wealth, and I enjoy its bounty.  But sometimes it has unintended consequences.  Like in the health care market.  When you put private corporations such as health insurance companies in charge of the nation’s health care delivery, there is an inherent conflict of interest.  The company’s raison d’etre is to increase its profit margin.  Nothing wrong with that if you’re selling shoes, but a third party payer can raise its profits only by denying health care or raising its premiums – and premiums are already prohibitively high.  By denying sick people coverage, or denying people the most expensive medicines even if that’s what’s best for the patient, or denying an MRI when a CAT scan is almost as good, or denying the patient a 3^rd day in the hospital when the actuarial chart shows 2 days should be just fine in most cases.  Private insurers ration all your doctor’s care on the basis of their bottom line, without regard to the patient’s best interest or his doctor’s best medical judgment.

In the proposed Democratic house plan, the public option would not have that profit incentive.   Private insurers typically have a 25% profit margin – higher than most businesses – whereas a government insurer could put that quarter of your health care dollar directly into health delivery.  That’s a lot of money turned around into direct patient care.  Furthermore as a low bid competitor, it would force private insurers to lower their premiums, deductibles and co-pays – which would lower their profit margins, but coming down from 25% to 15% is a hardship for no one but the stock holders.  And since stock holders are patients, as well, they’ll come out okay.

Doctors will come out okay, too.  They are under-reimbursed by Medicare, especially in Santa Barbara – and all the public payer systems need reform.  But some doctors are part of the problem as well, despite the physician at the meeting who seemed incensed by that notion.  I’ve known many doctors during my 34 years of practice, and they fall into 3 categories.  The selfless ones, who care not a whit about money, only about caring for their patients; the majority, among whom I number myself and my doctor-challenger that night – we care for and about our patients, we went into medicine to heal people and for intellectual challenge, but we also like to make a nice living, and we do just fine; and there are those for whom patients are merely an engine for their income stream, and I’ve known a bunch of those over the years, too.  I don’t think doctors who do expensive, unnecessary procedures are evil people.  But you have to ask yourself why America’s Caesarian section delivery rate has skyrocketed in the last 20 years – which is when private insurers began reimbursing for elective C-sections.  In 2008 30% of all births in this country were delivered by C-section – over twice the average in other developed countries, and our infant mortality is worse – and I have to believe that number would drop if, for example, a Public Option plan did not reimburse a doctor who merely wanted to do a C-section for the convenience of scheduling a birth during daytime hours.

I was accused of being disingenuous because it was obvious this Public Option was just a Trojan Horse for a Single Payer total government takeover of health care.  I don’t think that’s what it is.  Switzerland is a capitalist country, much more conservative in general than the United States.  Years ago they had the health care fight we’re having now.  Universal coverage was fought tooth and nail by, among others, the huge pharmaceutical companies that Switzerland is home to.  But the law barely passed, and now, years later, everyone is covered and the private insurance companies do a thriving business selling specialty, niche, and broader up-coverage to anyone who can afford it.

I’m not so naïve as to think any government bureaucracy will work smoothly, or quickly, or get it all right.  But it will change the playing field so that the patients – the American citizens – will get a fair break on access to health care.

The idea of American citizens brings up two issues for me.  There was a good deal of anger in the audience about this bill providing health coverage for illegal aliens.  First, that’s untrue – the bill specifically states that coverage is for American citizens.  Of course we all know the realities.  There are 12 million illegals here, and many of them use our health care system, often in the E.R.  Personally I think there are moral and humanitarian reasons for treating anybody who walks into an emergency room with an urgent problem, but I can understand the resentment about unnecessary use by people who haven’t paid into the system and don’t expect to.  Illegal immigration is a big problem, a drain on schools and services, especially in the border states, and it must be solved.  But to load it onto health care reform – to say we can’t do this kind of health legislation without dealing with how it’s impacted by illegal immigration – simply sinks the entire effort.  Each one of these problems is so massive that trying to combine their solutions into a single piece of legislation is ridiculous.  And disingenuous, if the immigration card is being played just to waylay health reform.  It’s like saying the main street downtown is full of potholes, but bank robbers use that street to make their getaways too, so if we fix the potholes it makes it easier for the bank robbers to get away, so we can’t fix the pot holes until we solve the bank robbery issue.  Let’s fix the potholes now, and next year we can try to deal with the bank robbery problem.

I also got the sense from the audience that “all those people” without insurance who showed up at the E.R. were mostly Mexicans without insurance, or whiners who didn’t really have to be there, or people too stupid to understand they could get health insurance coverage simply by forming two-person companies.  I have to tell you, most of the people I see and treat without insurance don’t look like illegals or deadbeats or idiots.  They look like you and me.  Some aren’t covered because they have pre-existing conditions, and some aren’t covered because they just can’t afford it.  Last week I had a patient, the sweetest girl, 23 years old, just out of college, with her first job, as a teacher’s aide, in a local pre-school.  She’d been walking one of her kids to his mom’s car, when someone’s big dog bit her hand.  Wasn’t officially on school property, so Worker’s Comp didn’t cover it.  She wasn’t sure how bad the bite was, but she knew she couldn’t afford to go see a doctor and pay out of pocket – she was barely making ends meet, had two roommates to share rent, counted pennies when food shopping.  So she washed the wound and put some Neosporin on it, and hoped it would get better.  It got worse.  When she finally came in to my clinic, her hand was swollen and she had red streaks up her arm.  The wound was badly infected.

At my clinic we’d customarily charge an insured patient $120 for a first time visit, another $190 for the Lidocaine and extensive debridement and wound repair I had to do, $41 for the X ray to make sure the bone wasn’t broken, $20 for the antibiotic I had the nurse give her by injection, $50 for the nurse’s injection services, $85 for a tetanus shot.  That’s over $500, but she had no idea how to come up with that much money at her pay grade, so I reduced her total bill to about $200, which I often do for uninsured hardship cases.  Even so, she had to borrow from her roommate.  But then I gave her prescriptions for two more antibiotics to take by mouth, and she called from the pharmacy in tears.  One med was $40, she could barely handle that, but the other one was $180, and that put her over the edge.  We finally worked out that she would only take the one, cheaper, antibiotic, and it might work alone or might not, and if not she was going to have to come back in, and the problem might be a lot more serious, might require hospitalization and intravenous antibiotics, possibly even surgery.

I was giving sub-optimal care.  To a hard-working, vulnerable young woman who we were entrusting to teach our children.  This is happening every day to millions of Americans, and it has to stop.  And tinkering with the details of the private insurance company monopoly on health care is not going to fix it.

Finally, a word about Death Panels.  As I said at the meeting – to an audience full of people shaking their heads dourly, as if I were lying or a fool – there is nothing in the House bill that remotely refers to death panels.  The relevant section states, in brief, that a patient may, at his request, consult with his doctor about end of life issues – hospice care, living wills, power-of-attorney, etc. – and the doctor shall discuss all those issues, and be reimbursed for his time.  But this isn’t about what’s in the bill, it’s about what you’re afraid it will lead to.  All I can do is tell you – as a doctor – your fears are unfounded.  The notion that any doctor, even a bad one, would pressure a patient to refuse extraordinary measures on his deathbed, is ludicrous.  Unless, of course, it’s the patient’s wish, and then the doctor would be obliged to go over options.  It doesn’t even make financial sense – a doctor would certainly make more money extending a patient’s life beyond what even the patient wanted, much more money than if he were to “pull the plug on grandma.”  To keep repeating this myth is a disservice to every American with an ailing older parent, and a poisonous fear tactic to distract us all from the important work that has to get done to reform health care.

A Public Option isn’t necessarily the only way to do it.  As I mentioned at the meeting, treating health insurance as a public utility could also work – private companies providing a critical service with guaranteed demand, licensed by government, profits strictly regulated to protect the public interest.  The point is, several approaches might work, and no bill will be perfect – everyone will always finds reasons to dislike parts of any bill.  In the current bill, for example, I’m disappointed that tort reform was not addressed.  I assume that was a political decision because if the lawyer lobby came out against the bill, with all the other lobbying pressures coming to bear, a bill would simply not get passed.  So I’m hopeful we can address tort reform next year – possibly between immigration and bank robbery.

In the end, the commitment has to be to provide health care access to everyone, for a reasonable price.  The details can and should be debated, but first the will to make it happen must be there.