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Health Care Reform

October 19, 2009

angheadshotwhitecoatFor my first blog on a topic I thought I’d start small. How about healthcare reform? Seems like a nice manageable issue to get through in a few paragraphs. Since we all know stories are the way to best express an issue, let’s talk about a few patients that I’m sure any of us who work in emergency medicine can relate. Names are fictitious but the description of these patients are realistic as to what we see on a daily basis in the ER (I use ER for emergency departments- I also liked the show when it first started).

Denise Johnson is a 19 yo community college student who has been feeling nauseous and having some lower abdominal pain. I diagnose her with her first pregnancy at 8 weeks. She has no health insurance and no PCP. We write her a script for phenergan, prenatal vitamins and folate and instruct her to follow up with the OB-Gyn on call to start prenatal care.

Bill Maxwell is a 50 year old part time construction worker feeling “dizzy”. You note his BP as 180/100. His symptoms appear to be benign vertigo after a full workup in the ER. He has a family history of heart disease and has no PCP or health insurance. You give him a script for meclizine for his vertigo and start him on cardizem as his blood pressure does not significantly drop in the ER. You have him follow up with the internal medicine doc on call and also give him the number for the local clinical that takes uninsured individuals.

Both cases demonstrate good ER care and appropriate management. Both patients fall into the 13% of uninsured patients in the United States. The statistic that is quoted is about 20% of patients who visit your typical ER is listed as “uninsured”. In some areas the number is higher and some lower. Some of these patients will pay some portion of their bill for care although that will vary greatly depending on where that care is delivered. In the best of cases each will find their way to a caring doc or clinic that will appropriately manage their condition and minimize the worst of the complications of their condition.

I think I’ve described the situation pretty accurately for most of us who practice emergency medicine in the US. I believe the system works well, especially for acute care where I think we are the best in the world, for any person who needs it. It is the patients on the fringe and who are more complicated where we lack good preventative care. This is, at least, in comparison to other “wealthy” or “developed” countries. If you look at most of the World Health Organization rankings you have heard the same story. We spend the most and get good but not great results (in comparison) for what is spent. We are the leaders in technology and high tech care. I’m sure some people will take exception with the statistics and to that I would agree. All statistics can be debated and they should be.

The real question for me as an ER doc is this. When I send Ms. Johnson to the OB-Gyn and Mr. Maxwell to the internist am I certain they will get the right care they need with the minimum of hassle? That is a question we each have to answer but for me the answer is mostly yes, for the most part. The reason they will get care is that the likelihood is the OB-Gyn or Internist will do the right thing and accept another non insured patient. Each practice may also try and find an appropriate clinic for the patient to go to minimize the patients’ out of pocket expense because one thing is for sure. In America, more than any other country, if there is a void someone is trying to fill it.

I have heard we volunteer more time and give more to charity than any other country. That is the American way and the American experience. When I was growing up I was a volunteer EMT. It was a service my community needed and to buy the apparatus we held bingos, summer carnivals and door to door campaigns to raise money. I was proud of that effort and the service I provided to my community. The question becomes at what point does the burden of the good people to fill the “gaps” in any system become too great and require a more coordinated, some read government, response. For every person the answer is different and that seems to be where we are in the health care debate.

Most people can get care if you look hard enough or travel far enough. Is it perfect care – well since no country provides perfect care we are left with the question what are we willing to tolerate as a society? And in the end there are people who can’t find that care or travel to get it. They make choices not to manage their pregnancy properly or take their anti-hypertensive drugs. Five months later our neonatologist will be there to treat the premature infant with the latest NICU technology. When they come in 10 years later with their stroke from uncontrolled hypertension our “stroke center” will be ready to treat them.

Some countries tolerate longer waits for elective procedures as the offset to cover all (or most) citizens with robust primary care. Some relatively underpay physicians to provide basic services to all. Almost all are lacking in something; rapid access to advanced elective procedures, restrictions on high cost pharmaceuticals or medical devices which may be lifesaving. These may also only offer a few more months of life or a modest improvement in “quality of life” at a high cost. Occasionally though, they provide a life changing improvement or that “cure” for the patient’s cancer. Who should decide?

The one debate we are certainly NOT having regarding health care is what I am willing to give up. Every interest group in the debate knows there must be some give. Whether you are a health insurer, pharmaceutical company, “high cost” specialist doctor, malpractice attorney, holder of a “Cadillac” insurance plan, AARP member, healthy young person (electively uninsured) or member of hundreds of other interest groups you gotta give up something. The only ones who shouldn’t give up anything are the primary care docs (God Bless You) and patients who have no access to insurance.

Finally (for this missive) people need to take some responsibility for themselves. Stop overeating, not exercising and allowing our kids have astronomical rates of childhood obesity. Enough excuses about it’s too easy or cheap to get fast food for dinner again tonight. That is surely not something Americans like; being told to do (or not do) something!

So I’ll keep thinking about Ms. Johnson and Mr. Maxwell in this debate and try and measure whether any of the plans working their way through Congress will really make it better for them and cheaper for all of us in the long run. I know I am the eternal optimist! Maybe I’ll continue this conversation as the debate moves its way through Congress. I certainly don’t have the answers, just lots more questions.

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