Angry Sinking Feeling

Posted by BMS on Monday, January 25, 2010 at 12:26 am

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.

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Category: a day in the life of a practicing physician,high quality health care for all

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