Healthcare: Beyond the Noise

Well, it seems that the people we elected to run our country have decided to take a little summer vacation before trying (yet again) to replace an imperfect healthcare act with a far less perfect one–the inappropriately-named Better Care Reconciliation Act. That’s probably for the best. Perhaps the recess will give them the opportunity to take in the advice that my fellow pediatricians have offered. And at the very least, it will give our youngest and most vulnerable citizens a few extra days to get sick without forcing their parents into bankruptcy.

Our system is fundamentally flawed. Costs are out of control, and nearly impossible to calculate. Lobbyists from health insurance and pharmaceutical companies have far too much control over the system. The administrative burden on our nation’s healthcare providers is crushing. And it is far more lucrative to perform a procedure to treat a disease than to prevent the disease altogether.

I never thought I would write this sentence, but perhaps Donald Trump said it best: “Nobody knew that health care could be so complicated.” Well, some of us did. But it was nice to hear him admit it.

As the debates continue, it sure would be nice if we could put aside the partisan politics and approach the issue rationally and with a sense of decency to our fellow human beings. There are a few key points that seem, at least to me, pretty straightforward:

  1. Primary care should be prioritized. Primary care physicians and other providers offer an effective and relatively inexpensive service. They help to prevent diseases, identify problems early, manage the majority of those problems, and reduce the need for more expensive specialty or hospital-based care. Primary care should be affordable to everyone, and the providers should be paid enough to encourage a steady stream of new graduates to enter the field. And there should be incentives for patients to utilize primary care when appropriate, instead of less cost-effective services.
  2. Emergency care must be available to everyone with true emergencies. Even if they can’t pay for it. This is already the case, and it simply has to remain that way.
  3. There must be no lifetime caps on healthcare coverage. I’ve taken care of kids who celebrated their first birthday before being discharged from the NICU. For some people, healthcare can get really freaking expensive–so expensive that it wouldn’t be uncommon to reach a lifetime cap during early childhood. What happens then? Who decides how much a child’s life is worth, or when we should just call it? I’d love to see a Senator or two have that talk with the family.
  4. Insurance companies can’t be allowed to exclude people for pre-existing conditions. This was one of the best things that the Affordable Care Act did. If insurers were allowed to cherry-pick only the healthiest patients, it would drive their costs down and their profits up. That would be a great deal for them. But it would leave a lot of people–myself included–without the ability to obtain healthcare coverage. Without appropriate care, those pre-existing conditions are more likely to turn into bigger problems, resulting in more suffering and higher overall costs.
  5. That individual mandate…it’s gotta stay. If healthy people aren’t required to have health insurance, many of them would decide not to pay for it. Most of them would come out ahead. But those who end up with significant medical issues won’t be able to afford the care they need, forcing them to postpone treatment. Then they’ll end up in the emergency room, once their disease has progressed to the point where it is more expensive to treat, has caused more complications, and may even be beyond hope. Taking away the individual mandate also results in a higher level of risk to insurance companies, increasing the overall cost to the sickest people.
  6. We have to address problems earlier. I’m not talking only about primary care and preventive medicine; I’m talking about bigger societal problems. Healthcare frequently gets stuck with the costs generated by our society’s failure to address other issues, like poverty, for instance. The difference between children who are always in the hospital and those who are managed entirely as outpatient is often their environment, not the severity of their disease. It’s whether their parents can afford their medication. Whether the family understands how and when to use a medication. Whether there is even a parent in the home when a medication needs to be administered. Poverty, poor education, and insufficient social services aren’t the fault of the healthcare system. But when left unaddressed, they become our problem. Handing healthcare the bill for the downstream costs of our collective failure to address these societal issues is like having a driveway full of roofing nails and complaining about how much money you spend at the tire shop.
  7. Children, at the very least, must be universally covered. That coverage may come through commercial insurance companies or government programs like Medicaid and CHIP. But to make cuts to these government programs, which currently provide healthcare coverage to 37 million of our nation’s children, would be inhumane. A child has no control over the financial resources of the family into which she is born. Nor does she get to decide whether or not she needs heart surgery, chemotherapy, or an organ transplant. And beyond the coverage provided for economically-disadvantaged or medically-complex children, Medicaid also provides crucial funding that allows children’s hospitals and pediatric specialists around the country to provide their services; without it, these services wouldn’t be available for insured kids, either.

You may have noticed that I didn’t have much to say about whether we keep our commercial insurance plans or switch to a single-payer system, whether we provide healthcare coverage or subsidies so families can purchase their own, or what model we should adopt for physician payment. I have opinions about these things, but I think that they (and other questions like them) are legitimate topics for debate–topics on which people could reasonably defend divergent views.

There isn’t a simple answer to this problem. Our world isn’t perfect, and the next healthcare bill won’t be, either–whether it’s passed next week or in 50 years. But it’s time for us to approach this issue rationally, take our ethical obligations to our fellow citizens seriously, and wait until somebody actually has a better plan before we torch what’s already in place.

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As always, your comments are welcomed (even if you happen to disagree). I'll get back to you as soon as I can. Please try to keep it civil--I reserve the right to delete comments that are offensive or off-topic.

2 thoughts on “Healthcare: Beyond the Noise

  1. It seems as if all the decision-making and discussion is based on abstracts, numbers and figures. It does not appear that any real life use cases are being considered at all. Perhaps that is why the bill seems so inhumane because They haven’t considered the effect on human beings. My eyes were open several years ago on the first night I volunteered at our local free clinic and a young mother who is diabetic came hadn’t have insulin for 2 to 3 weeks. As long as situations like that can occur this is not the greatest country on earth.

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