On Being Realistic and Hopeful

In the midst of the greatest financial crisis to come along in more than a generation, I am beginning to find hope. Not the kind of hope that allows me to think the crisis is going to be short or painless; though that would be nice, I am not foolish enough to think it a possibility. Instead, my hope centers around the fact that with great upheaval there is a tremendous potential for change. Not the kind of change that occurs in increments or at a glacial pace, but real change like the dismantling and rebuilding of entire systems.

With the pending failures of health insurers – a high likelihood because of the stress on financial companies at present – and with 78 million boomers expecting a health care system that is intact and functional, the best option will soon be for the nationalization of health care. The U.S. is the last holdout among advanced nations not to provide this basic safety net for its citizens, and now may be the best time to restructure our system to provide the most good for the largest number with the resources available. That is to say, it may be the best time because it will soon be unavoidable given the situation.

“You'll never get people to accept limits on health care. That won't happen in this country.” These words were spoken to me by a friend at work. He is convinced that citizens will not allow for any health care system that does not cater to them. He argues that people want what they want, when they want it and therefore, they will not accept any decrease in services they currently receive. But really, that “drive thru” mentality (as my wife refers to it) of patients exists only because we have allowed it. Ever since health care administrators started calling patients “customers” and decided “market share” was an important aspect of treating the people of our communities, we have invited those patients to dictate what it is we do because we have sought their approval.

But, as I see it, those days are coming to an end.

In the midst of a depression - when millions will be unemployed, without savings and without retirement accounts to fall back on - what's to prevent them from understanding the limits on health care? My sense is that the majority of Americans will soon begin to understand that something is much better than nothing. After all, when you can have anything you want, you want everything – but when you have nothing, you will accept anything. Don't buy that? Check out your local soup kitchen for proof I'm right.

Our next health care system needs the following to be functional: 1. It needs to be reality based; 2. It needs to include legal reform; 3. The cost of education must be reduced; 4. Funding should be adequate and provide basic coverage for all citizens. It is well past time for a reality based, adequately funded, practical and responsible health care system in this country.

We can do more with less if we do it reasonably. We need to stop performing tests simply to prevent a lawsuit; we need to stop doing procedures that will have little to no impact on outcome; we need to stop performing heroic measures when it is obvious they will not change the outcome. We have lost all sense of reasonableness and have instead clung to the mantra of honoring patient wishes.

As an example of how a reasonable system can work, consider how organ donation is handled. Today, there are waiting lists for patients who need transplants. These lists only include patients who are most likely to survive (they cannot have several other major medical problems) with the new organ so that the precious resources are not squandered. Thus, patients in need of a liver must not be actively drinking alcohol or abusing drugs; those in need of lungs cannot be smoking. Break the rules and you lose your shot. It's simple and prevents organs from going to those who can't show the ability to maintain their health.

A rebuilding of heath care in the U.S. must also include legal reform that removes the threat of frivolous lawsuits against providers and limits damages awarded for mistakes that are not life-impairing. We work and live in an imperfect world and deal with imperfect patients – with few exceptions most of us do our best and then some to make sure patients are cared for appropriately. We spend more money (via unnecessary tests and procedures) trying to cover our backsides than we do actually doing the things that matter. This needs to stop. Medicine should never be practiced from a defensive posture. Fear wastes resources and the constant threat of legal action makes many leave the field prematurely.

Educational costs need to come down to levels that encourage people with the ability to enter the field. Physicians are typically saddled with $200K-$300K loans upon completion of their residencies. This level of debt is daunting and prevents many from entering fields like primary care where reimbursements are minimal compared to other specialties like anesthesia. As of 2005, of the 800,000 physicians licensed in the U.S., less than 1/3 were working in primary care. Primary care physicians should be able to manage the ongoing care and treatment of their patients. To do this, they need to have fewer patients attached to their practices, while making an income that allows for them to not have to take on more patients than they can manage safely. To achieve this, more primary care physicians are needed – period.

Universal health should cover the basics for all citizens. Things like regular office visits, preventative care and screenings, necessary medications, valid emergent care and EMS services and hospitalizations. Necessary surgeries and tests should also be covered. Unnecessary treatments should not be covered by the plan. By unnecessary, I am talking about such things as emergency room visits for non-emergent complaints, the use of EMS for non-emergent transportation and tests like CT scans done at the insistence of patients and families. If patients want to pay out of their own pocket, then they are welcome to request such things, but if the government funded system is to work, it cannot be permitted to pay for nonsense.

None of this is revolutionary. All of what I have described above is practiced almost everywhere else in the world – and with good results. We are the ones who spend more on health care than anyone else, and we are also the ones who rank about 40th in the world for life expectancy and infant mortality. Clearly, we have gone off course.

The group most opposed to such a system includes those who benefit most from the current system and those who stand to lose with the new one. People who have worked as physicians and made a very good living (albeit while saddled with massive debt thanks to the cost of education) can be some of the most vocal about arguing against universal health. Also, many employed by insurers are quick to denounce universal health as an impossibility. Often, they go further and argue that no government could possibly run a universal health system with any sort of ability. Well, insurance companies spend upwards of 30% of their capital on administrative costs. Medicare, a government run entity, by comparison spends a paltry 4% - in line with other universal health systems.

But the group of detractors is getting smaller and stands to get smaller still. The chances of large health insurance companies surviving this crisis intact is absolutely zero. There have been and will be more layoffs and write downs. The reality of our new financial world is coming into view for many more people and the ones who will see most clearly will be the ones who have lost the most. Sadly, that number is increasing on a daily basis.

My own hopefulness rests with the assurance that very soon, the best option will be the only possible one left on the table and the number of citizens who insist on it will be unable to be ignored. Someday soon, I will work in a system that is fair and makes sense.