By ROB KIEFNER
Concord (N.H.) Monitor, Dec. 4, 2009
Amid chaos, misinformation and misunderstanding, the health care reform bill was nudged through the House of Representatives by the narrowest of margins. By not letting the facts get in the way of their blustering arguments, wacky lawmakers from both sides of the aisle offered lots of hype and heft, at times bench pressing the actual 2,100-page document to underscore the strength of their positions.
I thought, for a time, that outcome would be decided by virtue of which representative’s head exploded first in a display of feigned indignation about one aspect or another of the bill.
As a family physician, I rely upon my patients’ stories for insight into health care reform. Lost in the mind-numbing mumbo-jumbo from Capitol Hill are the stories of real patients who can’t afford insurance and small business owners who can’t offer it. The House legislation might make insurance available to my patient who is a struggling small business owner, but at an impossible cost. To add insult to injury, he’ll be fined if he doesn’t purchase insurance.
And for those patients who have “decent” insurance, there are always the struggles, which we share as their doctors, to obtain the diagnostic testing and therapeutic treatments to which they are entitled. By keeping the for-profit insurance companies happy, the legislation will continue to effect de facto rationing of health services by employing the hassle factor.
The costs associated with this bill are not at all clear. If projections are tied in to the “good faith” cuts promised by the pharmaceutical and insurance industries last summer, we are indeed in trouble.
We spend twice as much on health care, per capita, as any other industrialized nation. Yet by several measures of our collective health and wellness, we rank a piddling 37th in the world.
The House bill, with mega subsidies to the health insurance industry, seems to assure our place as No. 1 in the world – for health care spending that is. Within that 2,000-page tome is a mandate for universal coverage with all sorts of befuddling caveats. While health insurers will have to take on patients with preexisting conditions, they’ll do just fine with the increase in volume of patients and the ability to increase premiums. Those insurance execs are kicking back, popping another magnum of Dom Perignon, and reveling in their ability to influence people in high places. Money well spent.
Now I’m not a rocket surgeon, but I think that we can achieve close to universal coverage by developing a publicly financed, privately delivered system in which the 30 cents of each health care dollar currently wasted on insurance companies is channeled into actual health care. In the context of a single-payer plan, or “Medicare for All,” nobody dies for lack of insurance or goes bankrupt on account of medical bills.
Primary care is key
Health care financing is but one leg of the table of reform. An equally important support is primary care. By enhancing the financing of primary care training programs and assuring that reimbursements are commensurate with the costs of providing services, we’ll close in on the quality gap with countries such as France, Germany and Switzerland. Time and again, studies have shown that regions of the country well served by primary care and preventive medicine experience decreased costs across the board, with fewer expenditures due to excessive testing and hospitalizations.
The final two pillars holding up the table of reform are the general acceptance of evidence-based medicine and malpractice reform. We should not be paying for expensive and ineffective diagnostic procedures and treatments, though I do believe that guidelines, and not mandates, are reasonable to allow physicians some leeway in the management of challenging clinical scenarios.
By definition, evidence-based recommendations are a work in progress. The use of screening mammograms among women under 50 has saved countless lives, and this practice should not be abandoned or even modified until much longer-term studies are available. As with any procedure in medicine, patients need to be fully apprised of the risks versus benefits of cancer screening tests.
By practicing in accordance with good science and not speculation, we should be able to diminish the onerous burden of defensive medicine costs.
This brings me to the fourth leg supporting the table: tort reform, conspicuously absent from the House bill. Honest oversight, or a function of the millions of dollars thrown at Democratic congressional campaigns by trial lawyers? Now that’s a tough one.
Focus on doctors
As our elected officials preen and posture for the next part of reform’s journey through the Senate, it is important to remember that governments and insurance companies don’t deliver health care.
It is health care providers and hospitals, working with patients who are fortified with a sense of personal responsibility, that will ultimately control costs and improve care.
Though I do hope that some form of reform ultimately passes, I am concerned that this bill, like “Hillary Care” so many years ago, is destined to collapse from its own incomprehensible mass.
(Rob Kiefner is a family physician in Concord.)