America is in the throes of yet another ill-informed, childish debate, this time about how its citizens receive health care. Unless you are living under a rock – which given this heatwave, is a pretty good idea – you know that the Supreme Court of the United States just found that the Affordable Care Act is constitutional. There ironically seems to be more outrage about the Court’s decision not to overturn the law than there was when it passed by Congress. One supposes that conservatives, who for thirty years have railed vociferously against “activist judges” who “legislate from the bench,” are quite disappointed that SCOTUS couldn’t come out just this once to rule on political grounds instead of constitutional ones. But of course, the Supreme Court is not there to decide whether a course of action is advisable, merely whether it is “constitutional.” Given the wretched real-life consequences of decisions such as Citizens United, which invites billionaires, corporations, and unions to dominate political communications, and Florence v. County of Burlington, which allows strip searches for anybody under arrest – even false arrests or parking tickets – we should perhaps revisit these expectations for the highest court in the land. And so it is with the Affordable Care Act – according to the Supreme Court, it is constitutionally valid, to say nothing of advisable.
Abandon all hope! America is lost! God’swounds and woe betide us!
The online debate that has followed in a few short days is breathtakingly inane. Opponents of the law went straight into melodramatic hyperdrive, rending their clothes, frothing at the mouth and lamenting that THIS, THIS IS THE FINAL ACT, THE END OF AMERICA! The end of liberty and choice and baseball and apple pie! Everything was going just so great before, and now, here, it’s ruined!
The “arguments” in support of this view are frequently comical. There appears to be a strong correlation between being 1) a government employee with guaranteed healthcare paid by the taxpayer and/or 2) being a Medicare recipient and 3) lamenting that government is horrible and too big and thus everybody covered by the ACA is a leech on the system. Never mind whether MY Medicare is funded sufficiently by MY tax burden – everybody else is the freeloader but me. America is the land of the free, home of the brave – but not the bastion of the consistent worldview, clearly. Either way, being a vociferous opponent of the ACA requires painting yourself as the last honest man in America, the only one holding down a job or paying taxes, and someone who believes that the only thing threatening the function of American healthcare is “personal responsibility.”
Meanwhile, there was similar cluelessness from the cheering camp that said, “YAY! Everything is solved now!” – as if the Baby Boom generation was no longer twice the size of the generation on the hook to pay for this all, as if the economy was not continuing to be cratered, as if the whole mess of a system isn’t still on track to be pulverized by the the wildfire epidemic of chronic obesity, diabetes, hypertension, heart disease and Alzheimer’s.
Then again, who could think clearly about the Affordable Care Act? The thing is over 2000 pages long, adding yet more complexity to a system already beset by the world’s most tangled Rube Goldberg machine of regulatory bodies, for-profit insurance companies, government entitlement programs, tax revenue collectors, hospitals, doctors, employers, and – oh, yeah, almost forgot – patients. It is probably no surprise that America has retreated to its political tribes to yell about the results of this legislation, since there are only a few thousand people at most who understand what is accomplished by the introduction of this law. And perhaps only a few dozen have bothered to think about the future consequences on the health care system, economy, and nation as a whole. Out of 330 million Americans, those are not very good odds for a useful discussion about how to see that Americans are kept healthy.
A lack of clear explanations
Before, during and after the realization of the Affordable Care Act, one thing was missing from the national debate about reform, which careened oh so quickly into the idiot demagoguery of government murder committees and such. That was: a simple list of facts that would explain just what is deteriorating in American public health, why, and what needs to be accomplished. Only then could we proceed into a somewhat rational debate about how to move forward.
The Obama Administration and the Democratic party immediately dove, as is their habit, into bureaucratic language, incomprehensible minutiae, and bland happy talk about what this bloated package of legislation was going to accomplish. And of course, amidst the gargle of tepid Pelosi-speak, you can intuit lots of Good Things that will be the result of the ACA: insurance companies can’t refuse to pay for your leukemia care by going back and claiming you made a typo on the application, they can’t refuse to cover you because you got a mammogram one time, they can’t charge women more for the same coverage because they have complex lady parts; all of that seems like pretty reasonable reform of abuses by a powerful industry.
But in over 2000 pages, there is much, much more than that, making it impossible to really get a sense of what kind of reform we’re talking about. This leaves the door wide open for its political opponents to make these histrionic claims that everything was going so swimmingly before, and now we have ruined this beautiful system by imposing socialism on it, and giving everything to undeserving lazy people, while the hard-working will now be saddled with paying for everybody, which they weren’t before – AND THIS IS WHY AMERICA IS RUINED.
Of course, that point of view is ignorant, self-centered, inaccurate, et cetera. But in the absence of more compelling arguments, we are practically guaranteed to have this kind of lunacy infect the public debate in place of calm, reasonable approaches to keeping America healthy in the years to come.
Doctors have failed in their educational duty to the public
Fingers are being pointed all around in this web of misdirected anger. Republicans point at Obama, Democrats point at the obstructionist Republicans, libertarians point at the Supreme Court, women point at insurance companies, and all are certain of the misdeeds of the other. There is one group who has escaped all mention, and who need to answer for their failings, since they may be the only people who can help us out of this mess: physicians themselves. Doctors have failed to come forth and tell the truth about healthcare in America as only they can. They have the experience and authority to lead us to better outcomes, but have been reticent to enter the fray. Beside being terribly busy taking care of wave after wave of increasingly sick, increasingly elderly Americans, doctors are generally opposed to speaking publicly about any matter that touches politics. Their trade groups might put forth an opinion on proposed legislation, but individual doctors almost never do. This cedes the positions of authority to people who almost always have inferior knowledge of the system, not to mention frequent conflicts of interest due to campaign finance – politicians. It may be out of character, but doctors need to step up.
I know from up-close-and-personal how aware doctors are of the American health care system, its triumphs and its failings. My wife is Dr. Katherine Garland, MD FACP, an internal medicine physician and professor of medicine. She currently practices and teaches at a St Mary’s Hospital here in Saint Louis, Missouri, a facility which serves a “wide range of patients,” doctor slang for “some patients with private health insurance, some with state-sponsored Medicaid and Medicare, and a bunch with no insurance at all.” She has also practiced in downtown Baltimore and Washington DC, two more American cities that feature wide swaths of the population that are poor and uninsured. Much has she seen, and so much have we discussed about the day-to-day trials of the convoluted, ill-designed American system of health insurance. Between her and the myriad of physicians serving all kinds of patient panels in America – rich and poor, black, white, and latino, illegal immigrant and old-line Boston brahmin – a much clearer, much more dire picture of health care comes into view.
Allow me to summarize – no doubt inaccurately – the harsh realities to which the physician community must introduce us, in no particular order.
America already has universal coverage and socialized medicine – it merely has the dumbest possible version of it.
Here is the criminally ignored point in the healthcare debate that every. single. doctor. in. America. knows intimately – everyone in America can get health care when they come to the emergency room, irrespective of insurance coverage. It is illegal for hospitals or doctors to turn away the critically ill or women in active labor under the Emergency Treatment and Active Labor Act of 1986 (signed into law by President Reagan incidentally, for those political partisans keeping score at home). If you are dirty, smelly, drunk and without a shed of identification or proof of insurance on you and you walk into an ER and say, “I’m having chest pain” or “I’m having a terrible headache” – you have just “bought” yourself an in-patient hospital stay and a full panel of diagnostics. Hospitals will receive a $50,000 fine for attempting to dump patients who can’t pay. There is a de facto system of universal coverage for the poor, uninsured masses of the United States, it is simply the most expensive possible way of providing it. Doctors should point out that this trope that we’re “on the way” to have “socialized medicine” which “would be a disaster” is dead wrong – we do have universal coverage, just a stupid, unfair and expensive version of it.
America’s private healthcare system is the world’s most expensive by a factor of two and not at all the world’s best in terms of health outcomes.
There is a frequent talking point that America has the “best” healthcare system, one that is pure self-congratulatory cheerleading, unsupported by data. It certainly is the number one country in terms of spending, which the OECD lists at $8200 per person, as opposed to places such as the United Kingdom at $3400/person, France at $4000 per person, and Germany at $4300/person. A somewhat controversial study by the World Health Organization back in 2000 listed the United States as actually 37th in the world based on infant mortality, disease survival rate, access to healthcare, and other measures. Some have criticized the report as apples-and-oranges, but still other studies show the U.S. system as lacking on continuity of care and access, not to mention infant mortality (ranking below Cuba, Greece, and Portugal) as well as a variety of other comparators. There is no way to claim we are getting our money’s worth.
America’s private system is not more efficient than government-run healthcare – it is almost always less efficient, by design.
For all the fretting about government healthcare being a morass of paperwork and bureaucracy, the reality is that the U.S. private health insurance providers intentionally create time-consuming complexity to lock customers into their systems and to create a way to deny coverage based on technicalities. From refusing to pay for hospital stays, to denying coverage for medications clearly listed on their formularies, to inventing reasons to call new sicknesses pre-existing conditions, American doctors spend four times as much time – and money on the phone, fax and computer with private payers than their Canadian counterparts do with their national system. Every doctor you know spends hours per day arguing ridiculous claims with mindless bureaucrats, all so they can can achieve standard of care or keep their patients from going bankrupt because of denied coverage.
You don’t have to go out of the country to experience this either – the Veterans Administration hospital system in the United States, with its universal coverage and unified IT solution for electronic medical records, provides considerably less expensive care, with less growth in cost, and all with a patient population that has more homelessness, alcoholism, drug use, poverty, and post-traumatic stress syndrome than any other hospital system in the country.
This is no coincidence.
Americans are being excluded from the insurance system by the thousands every day.
Want to know the real state of the economy, far away from the stock market fetishists of the Wall Street Journal or CNBC? Ask a doctor. They know that hospital ERs are starting to fill up with well-dressed, sheepish former professionals who have been out of work so long and blown through any funds to pay for COBRA that they have to throw themselves on the mercy of the hospital for cancers that have been waiting too long to be caught in time, for infections that have run out of control, of diabetes that has gone from a problem with blood sugars straight to blindness and leg amputations. Sure, you can look up the statistics that will tell you that the number of Americans covered by employer-paid health insurance dropped from around 70% in the year 2000 to a new low of just 44.6% in 2011. But talk to a doctor, who has to deliver the news that their patient’s lymphoma might have been caught early had it been for preventative care – but now society will foot the bill of chemotherapy for a late-stage disease that will also likely kill that person. Get the real story, in all its details, with all the emotional depth that doctors must handle every day in this system.
It is time for a real plan for the future of America’s health
America cannot afford hyperbolic, ill-informed partisanship any more. It is clear that America’s political leadership is unable to articulate the true state of healthcare with sufficient authority. America’s physicians have the most information and the most trustworthiness of any institution left in the United States. It is time to make their voice heard.
The future of a healthcare system negotiated through political gamesmanship is too terrible to contemplate, and a better outcome is possible.