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September 18, 2008

The Politics of Healthcare

Patricia A. Kelly

The election is still coming and, although we’re presently arguing over putting lipstick on a pig, there are some important issues involved.


Healthcare in America is in crisis. According to a recent article in AARP, 56 million Americans have inadequate access to primary care. With all the talk about universal health coverage, where will people get referrals to specialists for needed care if they have no primary physician to provide them?


Primary care physicians face insurance and Medicare-related limits on patient billing, mountains of insurance paperwork and incomes significantly less that their specialist peers. They make money through playing a numbers game with their patients, working long hours and spending little time with each.


Emergency departments absorb their overflow, with overwhelmed triage nurses making decisions about who needs care most urgently. Waits of many hours are common among those seeking care.


Emergency care is designed to be just that – short term, life saving or symptom relieving treatment, meant to be followed up by a physician acquainted with the patient. If a primary physician’s case load is 2,000 patients, how well will he or she know anyone?


A recent article in the Journal of the American College of Emergency Physicians reports that relatively few patients understand their discharge instructions. Worse yet, very few realize that they don’t understand them.


Insurance companies not only decide what can be charged for physician services, but what tests will be reimbursed. So, in some cases, they are the ones practicing the medicine. In any case, if no one has time to thoroughly assess the patient, a battery of expensive tests is a logical choice.


If the tests aren’t done and there is a poor outcome, then the physician faces litigation. So, a case might be made that malpractice attorneys are the driving force behind medical practice.


Of course, the very expensive tests, not to mention lawsuits, cost a lot of money, so the insurance companies have to raise their rates and cut expenses. To accommodate this, they reduce reimbursement to the physicians, and so on, and so on.


In the emergency setting, the physician encounters an unknown patient who is near death. The team resuscitates the patient, puts him on life support and sends him to the ICU. We are definitely good at life support in the U.S.


Many specialists converge, each assigned to his own body system, and each working assiduously to keep that body system going. In talking with family, they discuss that system, and what could be done to benefit it.


Artificial life support can prolong the life of even a terminally ill patient for a quite awhile. At the end, if he is terminal, or, if he contracts a lethal infection in the hospital, after possibly hundreds of thousands of dollars of expenditure, (making insurance rates rise yet again), the patient dies.


Sometimes there are meetings where family and physicians get together to discuss the likely outcome for the patient. But, for the most part, that is left as a black hole in the middle of the room that all attempt to avoid falling into. In Palliative Care, they call it the elephant in the middle of the room.


Add to this the American tendency to ask for immediate gratification, preferably in the form of a small, easy to swallow pill. The fact that physicians only rarely censure one of their own, or require re-training for inadequate practitioners, creates our very effective recipe for disaster.


According to Cokie Roberts, drastic change will not be occurring in the immediate future. John McCain and Barack Obama each have a plan, with Senator McCain’s being the more radical.


John McCain wants to hold down costs and provide flexibility, with patients purchasing their own insurance, not employers. He hopes that this will lead to higher salaries. VA benefits would expand, but other public programs would remain unchanged.


Barack Obama proposes closer to universal coverage, more of a public/private insurance partnership, with children guaranteed coverage.


I hope we can come up with something. We’re definitely rowing down the river. We just haven’t quite gone over the falls – yet.


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