By Brad Cotton, M.D.
Emergency Medicine News, December 2017
Linda couldn’t afford the gallbladder ultrasound her hometown doc recommended. Six months later, she is in my ED. She has cholecystitis, a fever, and an elevated WBC. She can afford even less hospitalization and unscheduled surgery now.
“I can’t pay for this!” she told me.
But Linda’s family told her they needed her to be well. “I need you, Mom,” Linda’s teenaged daughter Jenny says. Like many in southern Ohio, Linda is attended by six family members. Family is a strength of the Appalachian culture.
Linda is the foundation of her family. She works nights cleaning offices and restaurants in her small town. She has no health insurance. Linda is often paid in cash under the table. Her husband Bob fixes cars in his garage, and he offers to work on mine to work off my bill. There are no good jobs in their town.
“You can throw the bills away,” I said, gesturing toward Linda’s two teens, “but you do need this gallbladder out now.”
I have seen thousands upon thousands of Lindas. An ACEP survey found that 80 percent of us report seeing patients who have not had diagnostic tests, skipped meds, and suffered medical consequences due to their inability to afford care. (http://bit.ly/2fApz9w) I submit that the 20 percent not reporting seeing such patients either work in unusually affluent neighborhoods or just don’t connect the dots, misdiagnosing Linda’s real problem. Cholecystitis is Linda’s symptom. Linda’s pathology, which is also our nation’s pathology, is the absence of universal health care.
Why does Linda not have access to health care? Here is where our political and ideological biases, every bit as destructive of accurate cognition as the much-studied anchoring and confirmation biases, blind us to the failures of and solutions for our dysfunctional health care system. Some would say that is because we have not allowed the market to work in health care. Others say the market has not and cannot ever work for health care. I am of the latter school.
The Commonwealth Fund compared costs, outcomes, access to care, and equity (how fair the system is) among Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. (The Commonwealth Fund. July 14, 2017; http://bit.ly/2x2IB2q) The United States ranked last or near last on overall cost, access to care, affordability of care, and equity as well as overall outcomes. The United States spends about twice as much per capita as other nations, yet ranked last on life expectancy after age 60, infant mortality, and survival after MI, CVA, and cancer diagnoses.
The United States ranked worst on patients reporting avoiding medical or dental care due to costs, high out-of-pocket barriers, insurance shortfalls, and problem paying bills, like my patient Linda. Sadly, the United States also comes in last on equity when higher versus lower incomes are taken into account regarding access and affordability concerns.
The United States is the only one of these 11 nations that treats health care as a free market commodity. True, Germany, France, Switzerland, and others use private insurers, but they are tightly regulated. Their premiums and offerings are guaranteed by the state, so much so that it is a misnomer to call them market-based. The United Kingdom, ranking very high on many parameters is like our VA—all docs and hospitals are run directly by the government. Canada and Australia are like our Medicare: Payment is government-guaranteed, while docs and hospitals remain independent. All other systems perform better than ours.
Emergency medicine requires that we objectively evaluate the facts. The Commonwealth Fund report bears further consideration, as do these two centrist volumes: America’s Bitter Pill, Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System by Steven Brill, and An American Sickness, How Healthcare Became Big Business and How You Can Take it Back by Elisabeth Rosenthal, MD. Information at Physicians for a National Health Program is always well-researched with integrity and thoroughness to a policy-wonk fault. (www.pnhp.org)
We have seen the Democrats’ ineffectual attempt to tame the market with the Affordable Care Act (ACA). We have seen the Congressional Budget Office estimating that the Republican proposals to repeal the ACA and allow the health care market to do as markets do will result in perhaps 30 million more Americans harmed like my patient Linda. Perhaps the experience of these other nations from the Commonwealth Fund report is factual data we should critically evaluate.
The practice of emergency medicine is more than just rescuing drowning swimmers as the river brings them to our doors. Just as we advise our patients to wear seat belts, go to AA and NA meetings, vaccinate their kids, and get out of abusive relationships, we need to protect them from whatever is throwing them in the river in the first place.