I haven't yet taken the opportunity this year to render my thoughts on U.S. health care and how it should be funded and implemented. President Obama's plan for health care has come before the U.S. Supreme Court and its fate has already been decided. We are waiting for the clerks of the Justices to write their opinions. The Republicans maintain, in a strange twist of logic, that people demand the right not to buy health insurance. With some exceptions of extremists, who would actually choose not to have health insurance if they could afford it? The Republicans will next argue that people have the right to be poor and that we shouldn't take that right away from them!
My mother was leaning toward the Republican argument until I asked her what she would have me do if someone entered the emergency room in the midst of a potentially lethal heart attack without health insurance. Should I save his life even if he doesn't have insurance? I asked. Of course, she answered.
"There's the rub," I responded. "Once you believe that we as a society have the duty to save people's lives when they are having health crises for which they cannot pay, then we need a way to pay for it. That's what we have now. The nation's hospitals provide a somewhat dysfunctional local health insurance by virtue of laws preventing them from turning people away at the emergency room door. Hospitals in New Hampshire have sued their state government because they are going broke from this policy arising from laws forcing them to provide care without any means of remuneration. It's also important to remember that when those who have not had health insurance come to the emergency department, their bills are usually larger than those who have had care, because more has gone wrong.
I found the interstate commerce debate confusing. It seemed simple to me that we must care for whoever comes to our door regardless of where they live. For example, our hospital in Brattleboro is the closest hospital for people who live in Hinsdale, New Hampshire. If they have an emergency, the ambulance is going to bring them to Vermont regardless of any other concerns. Our hospital is three minutes from downtown Hinsdale, while the closest New Hampshire hospital is 35 minutes away in Keene. I'm not sure how well New Hampshire insurance pays our hospital, but I know that we do not accept New Hampshire Medicaid for psychiatric services since it pays $23 per hour visit (less for shorter visits). That compares to Vermont Medicaid which pays $87 for a one hour visit. State lines don't appear to exist when it comes to medical emergencies and hospitalizations; only for routine visits. The New Hampshire to Vermont transfer works in reverse when we have really sick people in our hospital. The closest major medical center is at Dartmouth University, which is in Lebanon, New Hampshire. They send a helicopter to pick up our really sick people and bring them to the academic medical center for the advanced technology they have there. Apparently state lines don't matter there either, for we don't send people the 260 km to Burlington, Vermont, to the University of Vermont medical center just because it's in-state.
The proposal which makes the most sense to me is that of Senator Bernie Sanders of Vermont, who believes that local regions should control their own health care budget. I think this could work in Vermont because we could decide where the money is best used in accordance with our local values and practices. We might choose to cover supplements and fish oil and not the most expensive drugs in the pharmacopeia. We might add massage therapy for people with chronic pain and perhaps stop paying for anesthesia blocks since these do not appear to be better than placebo. We might change every six months as data and preferences change, but we could do that.
I do think everyone needs health care coverage. We need to know that we are covered in the event of illness or accident. Someone must pay for this coverage. It must come from health care insurance premiums paid by people or from tax funds also paid by people. Either way, people must pay for health care, either through taxes or through premiums. I would prefer taxes over premiums, but that is my personal feeling. I would prefer a decentralized system in which each locality has a health authority which is populated by a community board of directors who determines how our portion of the health care tax is going to be spent in our community. We could struggle together to make the hard decisions about allocation. We could engage in the dialogic process as we do that. It wouldn't be perfect, but no perfect decision making system exists. Plus if we had the money locally, we would be forced to think locally about our neighbors and friends and not abstract concepts.
In my experience, what no one wants to address is the escalating costs of health care and why they are not going to stop rising. Health care is only getting more expensive and will continue to become progressively, even exponentially, more expensive as time progresses. New technology costs money and everyone wants more technology (seemingly). New drugs cost more than old drugs, and everyone seemingly wants new drugs (though few new drugs work much better than old drugs). When we invent a new test, we rarely stop performing the old test that the new test was meant to supplant. Usually we do both tests.
The medicalization of life has generated tremendous costs for health care. Ordinary misery has been elevated to a pathological condition. Every ache or pain demands a label and a diagnosis. In my role as family doctor, people bring to me a myriad of symptoms in search of diagnosis. Most of these symptoms will defy diagnosis unless I can convince them that their symptoms are part of life. Life involves aches and pains. Life involves some element of suffering. We get tense. We get uncomfortable. We forget how to relax. We get anxious and experience the somatic symptoms of anxiety. Our lifestyle leads us to pro-inflammatory conditions. This irritates our joints, causes our immune system to produce pro-inflammatory cytokines which makes us feel flu-like, makes us feel depressed and more anxious, and promotes the development of other chronic medical conditions. This pro-inflammatory syndrome is just being recognized and has no real pharmaceutical treatment. Its solution is to sleep more, to exercise more, to eat an anti-inflammatory diet, to have more fun with other people, to stretch more, and the like. So much of family medicine is about moving people in common sense directions to reduce inflammation which will improve their symptoms. Laboratory studies don't really help me to do that, but are what patients often want.
Chronic pain represents another example from my area of practice. Countless thousands of dollars are spent on X-rays, MRI's, and CT scans of the areas of pain. They are really revealing. Studies have shown that the findings of these studies rarely correlate with levels of pain. They "hypnotize" an entire population of patients to believe that they are hopelessly immured in chronic pain with no hope of recovery, when that is not necessarily the case. Often, the same simple measures will work wonders with chronic pain and cost very little. Similarly, coaching people to lose weight and to exercise costs relatively little compared to the costs of being obese and not exercising, yet current health insurance does not cover these costs. If we had local control over our health care dollars, we could make decisions about these types of matters on the local level and spend our money as we believe would benefit us best. That's my recommendation for health care -- use tax dollars, cover everyone, give the money to the smallest local entity possible (village, township, shire, etc.), let the local entity decide how to spend it, and struggle with our unrealistic expectations of contemporary health care.