Healthcare Reform

So, with the passage of the Healthcare Reform Bill last night, and with the knowledge of my somewhat unique position as a medical student, I felt compelled to write this. I also sent it as a message to a conservative friend of mine who was asking for thoughts on the bill, and I think it turned out far more eloquently than I might have expected. Hope you enjoy.

I've been behind this whole idea from the beginning for several reasons. I will first, however, point out that I do not think it's perfect--there are several things I wonder/worry about, including any measures to address cost-containment in medicine without first addressing the huge problem of defensive medicine in this country (that is, the fact that far too many doctors waste money on tests and things that are unnecessary for patients, but only done because they fear being sued for missing something that has a 1 in a million chance of happening) and the prospect of undervaluing the exceptionally hard work of doctors and healthcare professionals in the name of "keeping costs down." In that respect, I'll probably be lucky as a doctor because I'm interested in primary care, which will most likely be paid *more* in the future because primary care doctors will come to be valued more than they are now because of their focus on preventive medicine. But it is obviously still an issue, and the fact that I will still make excellent money as a doctor will put me in a higher tax bracket than most, which means the new tax increases will affect me more than a lot of people.

BUT. Oh, but. As my not-so-beloved George W. once said (in another context, obviously), "The essence of civilization is that the strong have a duty to protect the weak." And that is a dear, dear idea in this country, and has been from day one. It's also a dear idea to me as a Christian. Jesus healed the sick, no questions asked. Those who have the ability to take action, not only can but must do so. And in this country, we do that in many ways--we provide for disasters with FEMA, we help people who lose their jobs when the economy goes to crap with unemployment, we help the elderly with Social Security and Medicare. The whole idea here is that we are a rich, prosperous, and well-meaning nation, and as such we take care of those who temporarily cannot take care of themselves. Interestingly enough, as much as most Americans cherish those values more than almost any country, we are the only advanced nation of the world that does *not* offer our citizens healthcare as a right. We do not heal the sick without first asking how they're going to pay. Now, I'm not saying that a single-payer system like they have in most European nations is ideal either, but it is reprehensible to me that 47 million people in this country have no way to pay for vital healthcare expenses.

I have close friends whose families have gone bankrupt because of an automobile accident that left their father injured and unable to work, but with hundreds of thousands in medical bills. I see patients every week who refuse to take medications that will save their life because they must choose between the pills and their children's home/food/clothing. Until last night with the passage of this bill, my own sister would have been unable to obtain health insurance other than Medicaid (which isn't necessarily a horrible thing, mind you, but would have meant she had to change doctors--which isn't great when you have a very long and sordid health history) because Down Syndrome is the ultimate pre-existing condition. With the passage of this bill, my mom will now be able to get her coverage like she has had her whole life, keep her doctors, etc. That alone is enough to make me cry tears of joy over this reform.

Another reason I support this bill is because it will, hopefully, in the long run actually reduce the current inordinate expenditures on healthcare in the country overall. Right now, the vast majority of people seen in emergency rooms across the country are there because they are uninsured and have no doctor they can go to. I don't know if you've heard of EMTALA, but it was a mandate put in place many years ago requiring all ERs to treat patients regardless of ability to pay. This is, at heart, a Good Thing--the Hippocratic Oath requires it, after all. But the problem with it is that anyone who needs any care at all can wander into an ER and must get treated. And what this translates into at this point is that hundreds of thousands of people in ERs are there for simple ailments like colds, coughs, and sore throats. They can't pay to see anyone else, so they go where they can to get medicine for their kids/parents/spouses/etc. It's understandable, but the problem here is that it costs TOO much. Because over 50% (and that's a rough guess...honestly it's probably much more) of the people who show up in the ER on any given day are uninsured, the hospital has to get those costs back somehow. And so they charge everyone else more. People who *can* pay get charged 5x as much as whatever they're receiving costs, simply because the last 4 people behind them couldn't pay for it, and the hospital has doctors to pay and medicines to buy. That translates to higher costs for you out of pocket, but even more it translates to higher costs for the insurance company that's paying on your behalf. And that translates to much higher premiums. Now to make things really confusing, it also makes things much worse because the insurance company paying for you won't actually pay the full amount the hospital charges. So when the hospital charges you 5x the price of your tylenol, the insurance company will only pay them maybe 2x the price. But the hospital still needs the 5x price to pay for the drug and doctors etc. So instead, the hospital charges 10x the price, because then they know the insurance company will pay 5x. And costs go up--and will continue to go up, if we do nothing. It's one of the reasons that our country is slated to spend up to 25% of the GDP on healthcare within 10 years. This is in comparison to countries like Canada, Germany, England, and France, who all have government-run systems but spend approximately 10% of their expenses on healthcare--with NO better results than the US. In recent studies, the US ranks #1 in only one aspect of healthcare--Cost. In outcomes, we are number 37. Much of this is because of the vast number of uninsured patients who could be much more easily and efficiently (and, most of all, more cheaply) at a family practitioner's office--if only they were insured. This bill will provide insurance to 37 Million Americans who have previously been without it, which will hopefully eventually translate into lots more people getting access to primary care docs, and lots less people showing up in the ER with an earache. This passes the savings onto the insurance companies, and you. (And people get medicine they need without shelling out their savings--it's a win/win!)

The bill also creates capitalistic events in healthcare. By setting up these new insurance exchanges, insurance companies will actually have to compete for consumer interest--they'll have to offer better coverage at a lower price in order to get people to buy their plans, which not only drives down costs for us but is the essence of Capitalism (which is one reason why I've been so bugged by all the Republican opposition to this as a "Communist" idea). Insurance companies right now have all but a monopoly on us, with the ability to raise rates or deny coverage indiscriminately, especially to the people who need it most. I've seen it in my family and I've seen it in the hospitals where I'm starting to work--it's way too common for an insurance company to simply say "No" to paying for an expensive medication or procedure without any reason, even though it is necessary or life-saving. Insurance companies look out for one thing--the bottom line. I'm not saying it's not within their right to make money, but I don't believe it is within their rights as companies to exploit the American public in the name of profit, especially those who are at their weakest and most vulnerable in a time of great need.

Other good things of note: The bill allows parents to keep kids on their insurance plans until age 26, which is much later than lots of them do now--and helps out a LOT because the 18-30 age group has one of the highest rates of un-insured people, mainly because this group contains students and recent graduates who may not have jobs, or don't have jobs that offer insurance, or just feel that they are not likely to get sick and that insurance isn't worth the money. It also closes the Medicare "Doughnut Hole" for seniors where their prescription drug coverage doesn't kick in until they've paid X amount out of pocket. It allows for doctors to actually get paid for visits in which the sole purpose is to discuss end-of-life issues with elderly patients--to set out living wills, ascertain the patients' wishes, etc. (currently, these discussions are held all-too-infrequently, because Medicare doesn't cover them as doctors visits...which leaves far too many seniors without any recourse to make their wishes known. This is where the whole "death panel" rumors got started, but it's actually a very, very Good Thing so that older people can let their doctor know that "no, I don't want to be on a ventilator" or "yes, keep me going until there's nothing left in me," preventing doctors from doing something against their wishes or placing such difficult decisions onto distraught family members at the most inopportune times.).

But all in all, my most ardent support for the reforms are emotional. I know that I am one of the lucky ones right now. I have health insurance, and it's pretty good. I'll probably keep it just the same even once these new reforms come across. But in my heart I know that every time I see someone who has lost their job, or gotten cancer at a young age, or been in a car wreck and paralyzed, I know in my heart that It Could Be Me. There is no guarantee that D won't lose his job and with it our insurance. There is no guarantee that I won't go out tomorrow and get run over by a Mack truck and need thousands of dollars in drugs and surgeries. And if one of those situations should arise, I sure as hell hope that there would be some sort of safety net available to me--that society would not turn its back. Until now, there hasn't been. Starting in 4 years, there will be. And I don't mind paying higher taxes because by doing so I will secure for myself the peace of mind that comes with knowing that in the event of catastrophe, I will not have to worry about myself or my loved ones losing everything, or having to make terrible decisions, in the name of keeping me or themselves well. And I wouldn't wish that on anyone--so that means that I don't mind paying a little extra to provide for my neighbor, too. Besides, if I'm paying for his healthcare, he's also paying for mine.

So in summary--yes, I think this is a momentous step forward for the American people. I think a lot of the nay-sayers will realize once they get to keep their insurance just as it is, once they can provide better for their adult children, once they can see that there are no "death panels" and the bill is firmly set against public money being used for abortions, once they realize that they might just have the opportunity to get some cheaper deals on their insurance and not get dropped when they have a heart attack, that this really is an excellent plan. Is it perfect? Far from it. But it is necessary. Our health care system now is in shambles, and will only fall apart more as the years go on. I commend the President for actually sticking to his campaign promises and getting such massive reform passed within a year and a half of his election--and that determination and follow-through is one of the reasons I voted for him, and will most likely vote for him again.

*steps off soap box*