At this point it seems like everyone is frustrated with health care reform. Liberals feel betrayed about the public option and worry that we’ll see little actual “reform.” Conservatives are skeptical about the proposals’ ability to control costs, and worry that expanding public programs without stronger cost controls will leave our country further in debt. Having debated compromises, and compromises of those compromises, many of us are left wondering whether health care reform even matters anymore. Well, as an American, I am disappointed in the broken political process; as a progressive, I worry my core values of justice and equity are being undermined; but as a doctor, I cannot give up on reform.

More than a year ago, Mr. Nelson*, a hypertensive man in his 50’s with two grown daughters and a college bound son, came in as a new patient. He had lost his job as a salesman and with it his health insurance. For awhile, he paid out of pocket for the medication prescribed by his previous doctor, but he could no longer afford them. The community health center where I work offers sliding scale payment and low cost medications, so when he began having severe headaches, he came in to see if we could help. His blood pressure was sky high and I was concerned that he could have a stroke, but he did not want to go to the emergency room fearing the costs. Instead, I wrote a few prescriptions, saw him several times over the next few months, and we finally got his blood pressure under control.

I saw Mr. Nelson again a few weeks back, and he has still been unable to find work. His wife’s employer does not offer health insurance, and with her salary and his unemployment benefits, their income is too high for Medicaid. He could purchase coverage on the non-group market if it was affordable, but he has looked and this is not an option. Over the past year, I have been worried about his daytime fatigue and snoring, and I suspect he has obstructive sleep apnea. However, he cannot afford the thousands of dollars for a sleep study and respiratory equipment, so he must delay this medical care. It is a gap that the health center cannot fill. Each visit he is upbeat about his family and his blood pressure, but I cannot help but worry that sleep apnea is causing permanent damage to his heart and lungs.

I have other patients like Mr. Nelson, and I’m sure there are many other Americans out there as well, who are just getting by, and maybe cutting their pills in half to make them last, and delaying medical care as they focus on more pressing matters like putting their kids through school. The health care horror stories are heart breaking, but thinking about my patients on the verge of a bad outcome or one illness away from bankruptcy, I feel impassioned to demand reform now. We cannot wait for the perfect plan. A health insurance exchange with subsidies for private insurance is not the same as a public health insurance option, but it would offer affordable coverage to Mr. Nelson. If 45,000 preventable deaths annually are attributable to lack of health insurance, the Senate bill, which covers 2/3 of the uninsured with subsidized private insurance and expanded Medicaid, could potentially save 30,000 lives. If this is not the purpose of health insurance reform, I’m not sure what is.

Many are calling for the House to pass the Senate bill, and fix issues like the level of premium subsidy via reconciliation. This won’t remake the American health care system into a model of efficiency and equitability, but it does move us from debate to action. It will help 30 million Americans who are uninsured. It will provide security to those with private insurance. It will strengthen primary care, prevention, and wellness. Waiting any longer is just not an option.

*I thank Mr. Nelson for allowing me to share his story. I have changed his name and other minor details in order to protect his privacy.

The Thursday before the unfortunate election in Massachusetts that I am sure will deal the coup de grace to an already paralyzed senate, I saw a 54 year old man, let’s call him Joe, who was sent to me, a cardiologist, by his primary care doctor. By his history and ECG, there was no doubt that the man had suffered a myocardial infarction at home in the middle of December (something his PCP thought he had to confirm by a nuclear stress test probably costing several thousand dollars). It was also clear that Joe was self-employed, uninsured, and  his finances were in shambles. In fact he admitted that he had to “raid” his childrens’ bank accounts in order to pay for heating oil and the state sales taxes he owed, which were due the next day. The opportunity of any myocardial salvage had obviously passed and as the patient did not have angina and no ischemia on his stress test, I thought that medical therapy would be a better option that submitting him to a cardiac catheterization. As I started to tell the patient that as a minumum, he should take aspirin, a beta blocker, an ACE-inhibitor and a statin, the first question was “How much will that cost me?”. After that, further recommended test (such as an echocardiogram) were only going to happen if his care was “free”. Unfortunately, this is a common scenario.

With health care reform on the verge of collapse, I guess all of us have developed a sinking feeling – at least the ones that thought we’d finally had overcome the US malady we call “health care” and were on the way to recovery. It is an angry feeling, and a depressing one. Mostly, I just don’t want to understand, but I am afraid I do. I just read today’s New York Times “Prescription” piece for January 23rd. It seems to confirm what I had suspected and in fact what I have heard from my patients: America has been duped out of believing in health care reform. The opponents of the process that would  insuring most Americans have successfully sown so much doubt and misinformation that many citizens now think it is a bad idea. We live in a scary era – can anyone blame the people? Unfortunately, it is they who will suffer.

The system that has been devised sounds too complicated, too expensive – and critics from the other side complain it does not cover enough people. That’s all good, I can see the point, particularly the one about cost, which is scary, in particular with the backdrop of two ongoing wars, a slowly (or maybe not yet) recovering economy and high unemployment.

It seems, however, that many object on the basis of the principle of liberty, aversion of higher taxes and government mistrust. Coming from Germany to the US now almost 10 years ago, it’s something I’ll never understand. It boggles my mind that free choice (i.e.the choice not to buy insurance) would top the principle of the “common good” and solidarity with the less fortunate. The NYT piece described the opposition ordinary citizens. Charles Burke, a 55 year old man managing a cafe, is reported stating he was against mandatory insurance as he has always paid out of pocket; and Irving Cable, also 55, as saying “I won’t pay it (…) and I’ll shoot the first person that tries to make me go to jail because I will not buy health insurance“. This sort of stance only makes sense if we really are consequential: if you do not have insurance, you pay with you own money. Any sort of subsidy, be it directly to health care consumers or indirectly through government payments for charity care, higher premiums that finance jacked up hospital and health care provider fees, is in fact a form of solidarity payment, though not a just or equal one. If you offered Mr. Burke and Mr. Cable a refund of every cent of any Medicare Tax he ever paid, at the expense of forgoing any government paid health care ever, maybe they’d accept. And maybe it would work for them, as they may never get sick. Maybe they won’t get heart disease or cancer and quickly end up with bills a multiple of what their savings might be. But maybe it won’t work, and they’ll end up just as Joe.

The problem will be that it will be less likely in the future to find someone to provide free care, in particular care that conforms with the standard.  Payments are on the decline, the baby boomers are coming of age and less and less health care providers are willing to work with Medicaid and Medicare patients. This may sound morally objectionable, but they are within their rights and one has to conissr teh economic situation, salary for staff, rent etc.  Others will leave Medicine altogether. At some point coverage will be so thin, it will significantly delay care – already it is said that 45,000 people die yearly due to lack of insurance. Indeed, judging by the fact that even I, a healthy, young, insured man cannot find a primary care doctor that is accepting patients in my city, we may already beyond that point.

Maybe we have to hit rock bottom? When we do,  it will be so more painful.  Many seated members of congress won’t be there anymore, having retired or been voted out. But as they would probably lose many Medicare benefits,  maybe they should be paying attention now.

(Crossposted at CureThis)

The most recent edition of San Francisco Magazine (which I read only when I see it strewn across piles and piles of books, journals and mags at my in-laws’ place in Sonoma) features a run-down found here on Healthy San Francisco, a health care access system for SF residents to receive care at nearly all health care providers in the city (My long-time SF friend reminds me that it’s not a health insurance plan so what you do when you get alcohol poisoning in Napa or get shot in Oakland – or vice-versa – is beyond me). I am looking forward to actually reading the thing and learn about its inner-workings, but what I find most intriguing is this commentary by SF Mag’s Editor-in-Chief Bruce Kelley.

Kelley states:

When it comes to national healthcare reform, I think we should throw participatory democ­racy out the window. This one policy debate would go better if the American public were silent and disengaged, refusing to blog, carp, watch Fox News, or exercise its voice. It would also be helpful to suspend the constitution, strip all interest groups of power, and install a temporary dictatorship. One smart person would make the final decision how to address the healthcare disaster. She’d be advised by other smart people. She would wave a wand. Then Congress would return from a short hiatus, and the sausage-making would resume.

Kelley goes on to tell that that’s basically how Healthy SF came to be – without anyone actually noticing – and since it’s such a hit, we should replicate the process and fix US health care a la SF.

Even though it doesn’t really matter, I gave it some thought. Maybe he’s right. Let’s get the right person to just…DECIDE. Of course, remember the last “decider” we had in office…

What about Obama? Well, are we talking Candidate “If I could start it all over again, I’d do single-payer” Obama or President “Let’s cut a deal with Big Insurance and Big Pharma so they play nice” Obama?

I thought again…how participatory is our national democracy now anyhow? When I yell or email or fax or call the Hill, who is actually listening? The play by the Golden Rule – He with the gold, makes the rules.

Whatever happens in DC, we need to point our eyes and efforts locally and follow SF’s model. We can keep better eyes on the gold when it’s in our own neck of the woods. But, we should be careful what we wish for in hoping other parts of the US take SF’s lead and steamroll health care reform of their own.

Kelley dreams “If only the nation were more like San Francisco.”

Amen to that.