The "S" word... Socialism...

In conversations about healthcare policy and politics, I find that someone, sooner or later, says the "S" word - socialism. And, everyone involved cringes, as though we've spoken of some dark sin, or Harry Potter's "He Who Must Not Be Named." Like Darwinism, the word takes on an emotional content that is much more than it might deserve. (The Darwin talk is for another day...) Let's take a look at what the word might mean, as it applies to healthcare policy.

That great resource wikipedia defines socialism , in part, as:

a broad set of economic theories of social organization advocating public or state ownership and administration of the means of production and distribution of goods, and a society characterized by equal opportunities for all individuals, with a fair or egalitarian method of compensation."

So, that's might be much more broad that what most of us would really mean when we talk about healthcare policy and socialism. What most of us are talking about is changing from access to healthcare being for only those who can afford it, to a setting where access to basic healthcare services is available to all citizens, as a benefit of citizenship.

The concern that most people have when they speak of socialism and medicine is that the State will be in the business of purchasing health care. (Well, I gotta break it to you - the State already is! Over half the obstetrical care in our state of Washington is paid for by the taxpayers, as only one example.)

But, what's so wrong with the idea of the State ensuring that we all have access to health care?

We think of basic education as a right of every citizen. Therefore, it's provided by the State. So, it's "socialized."

We think of security as a right of every citizen. Therefore, it's provided by the State as federal, state and local law enforcement. And, on a bigger scale, as an Armed Forces to protect the integrity of the country. So, it's "socialized."

We expect protection from fire. Therefore, it's provided by the State. So, it's "socialized."

And, I don't hear anyone getting upset that "the market" isn't allowed to determine what level of police protection I have access to, what grade I can complete in school, whether the firefighters will come to my house in an emergency.

In fact, the issue of socialism is addressed in this article on the Physicians for a National Health Plan website, describing a "consumer-driven fire department." Take a look at the commentary, and the video demonstrating the concept.

So, let's take it step by step:
1) Is access to health care a right, or only available to those who can afford it? (I've often chuckled at the sign which hangs outside a medical practice I know which asserts "Excellence in Patient Care." It seems they just left off the next line: "If you can afford it.")
2) If you think it's a right, then society has a responsibility to ensure that all members of society can access this right.
3) If our current system has not delivered on this right, then we have a responsibility to step in, as a "government of the people."

This panel discussion on NPR would seem to agree...

But, let's get past the emotional baggage of the "S" word, and "the market", and get to work on a solution!

The President's Address, 2/24/09...

I was particularly interested in listening for Mr. Obama's address to congress. The transcript and video of his address are available on the White House blog, at http://www.whitehouse.gov/blog/09/02/24/The-Presidents-address-Excerpt/. So, what did he really have to say about healthcare reform?

"I suffer no illusions that this will be an easy process. It will be hard. But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of our health care has weighed down our economy and the conscience of our nation long enough. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year."

I'm particularly interested in the approach... he mentions the healthcare meltdown as weighing down "the conscience of our nation" - that's a hint that he and I would agree that we have a moral failing in the system of healthcare rationing we have in America. (Oh, you don't think we have rationing? Just ask our uninsured if they have access to the most basic of preventive services - they don't do pap smears in the Emergency Department, Mr. Bush. Or, ask our nation's retired military if they can find a local specialist, or even primary care doctor, to take care of them. I've talked about this 'economic rationing' before...)

But, the language that is stressed most is that America demands healthcare reform as an economic issue. Finally! Someone is saying it out loud! If you can't agree on the morality issue, then I think we can all find that we should work to reduce the high cost of healthcare, as it is a significant contributor to our economic burden.

I've often told of the per capita cost of health care as it relates to my own age... In the year I was born, 1962, the per capita cost for the US in the provision of health care was ~$200. And, the money we spent on health care was something like 5% of our GDP. The latest numbers show that per capita healthcare costs are now ~$8000+, and has risen to represent 16.3% of GDP in 2007. And, the trend of an aging population and costs rising faster than inflation would anticipate that healthcare costs will rise to 20% of GDP in 2017.

How does that compare with other countries? The data reported in this article is now several years old, and lists US per capita costs as $4000 in 2001. But, the article does have a nice comparison of costs across countries.

And, the journal Health Affairs has a nice editorial piece which calls for reform now. My favorite comment in the article is the revelation of the two major barriers to reform: "Democrats and Republicans".

So, the president is positioning healthcare reform as an economic issue, and now our task is to be diligent to watch that the reform process still includes the moral issue in the proposals.

"Yes, we can."

Healthcare as a right...

I've talked about this issue before - access to adequate health care as a basic human right. As my son scanned the news last night, for his journalism class, he paused on a story about this very issue. The commentator opened by making the statement that prisoners are the only Americans who have a right to health care granted by the Constitution. "Really?", he said. Yeah, really...

The eighth amendment guarantees the right of prisoners to be free from cruel and unusual punishment. And, the Supreme Court has affirmed that lack of timely access to medical care would be cruel and unusual punishment.

This comes to light as we are all reeling from the Great Recession. And, because the State of California has so many more prisoners than space to keep them, we are reminded of this right to health care. You see, a recent decision by a panel of federal judges tells California that they will need to release 55,000 prisoners, since the overcrowding conditions impedes this access to health care.

So, to extend this analogy, if the US Supreme Court were to affirm that access to health care is a fundamental human right, as does the World Health Organization and the United Nations, would that mean we would then have a responsibility to send 46 million of our citizens to another country, one with universal healthcare access? (46 million is the often-quoted number for the number of uninsured Americans; with the Great Recession, we have certainly seen the number of newly-uninsured patients in our Centers increasing.)

It's about time...

It's been way too long since I have commented here; ...

We find ourselves in some new days.  All of us.  And, I guess, "It's about time."

At our Community Health Center, we've been feeling the changes.  In the late fall, one of our Behavioral Health Professionals sent out an email asking for help.  You see, she had been finding more and more patients who were seeking help because they were losing their homes.  Her plea:  does anyone know of any resources to help these people?  The answer:  No, other than to refer them to the limited shelter beds available in our communities.  The Great Recession is real, and it's touching us now.

I had a wonderful chance to hear a leader in the National Association of Community Health Centers (www.NACHC.com) speak at a regional conference in October.  Dan Hawkins is Senior Vice President at NACHC, and in those days leading up to the election, spoke of the differences in the candidates plans for healthcare reform.  (Run this google search for "Dan Hawkins" and "NACHC" and you can see some of the work Dan has done for Community Health Centers.)  The analysis of Mr. Obama's plan offered some promise.  Maybe now we could do something together to get this fixed... As I did a photowalk around Denver, I was struck by the message of hope echoed in the sign, "All Together Now".  

But, where are we now?  The country, and the world, has turned nearly all attention to the economy, blaming greed and housing and bad business practices for the onset of the Great Recession.  And, the nation and it's leaders seem to have mostly forgotten about healthcare.  

And, I think back to many discussions I've had over the past few years.  Discussions about how inhumane our current healthcare "system" is toward our less-fortunate neighbors.  Even our previous President thought that the Emergency Department was the answer to the millions of children he had denied access to healthcare by refusing to sign the State Childrens Health Insurance Plan into law.  "After all, you just go to the Emergency Room."  [Our current president sees this issue a little differently.]

And, during these discussions, I'd often hear the sentiment that, if the poor people need something else from our healthcare "system", the should just use their political power to influence our elected leaders to make it happen.  The poor, I'm afraid, don't have that power.  If they did, perhaps they wouldn't be poor!  

But, now, all of us are poor!  The list of names of those losing billions to Mr. Madoff includes many people who are smarter than the rest of us.  And, have you taken a look at your 401K lately?  So, now, maybe the "nouveau poor" will be able to speak for the "old poor".  Maybe now, we can really turn our attention to the work of creating a healthcare system for all of us.  Even the prestigious New England Journal of Medicine sees that there may be a silver lining to the recession which is causing so much suffering now - finally, healthcare reform.  

It's about time...All Together Now...

A new plan!

We had a chance to visit Old Mill Days (http://www.oldmilldays.com/) in Port Gamble, a community near our home in western Washington this past weekend. And, like lightning, I was struck with the solution to our HealthCare Meltdown!

It came to me in an unlikely place. It was listed on the bottom of a sign in front of a carnival ride. It was a beautiful day - sunny and warm. The leaves have started to turn a bit. I could hear the screams and laughter of children, of all ages, as they enjoyed the rides. And, there it was - the solution to all the problems that plague my work week!

So, that's it! "Please, no major health issues!" Simple, straightforward. I think it could garner bipartisan support.

Now, I've got to go back to work...

"The Best Healthcare System in the World"...

I'm always struck by how many of my fellow US citizens fail to see the great failings in our healthcare "system". I say "system" because we certainly do not have a cohesive, organized, orchastrated approach to providing our citizens with health care, but rather a series of niche providers, many with an entrepreneurial underpinning - we're all in it to make money! (If you've read my blog, you know that I'm a physician working as an employee of a community-owned nonprofit medical practice serving the poor, and I recognize that most physicians didn't go to med school thinking it was [only] a great way to make a living, but that we wanted to be in a helping profession. But, I would argue that the institutions of care are very much dependant upon profit, even with the best of intentions...)

I sat with a patient Monday who came in to seek care for rectal bleeding. He had met me several months ago with this problem, but couldn't find a physician willing to do a colonoscopy for less than $1400 cash. He is one of the working poor, uninsured. He has had increasing concern that something is wrong, and comes back seeking this testing again. (We are a primary care clinic, and have depended upon specialists for these sorts of tests in the past. As time has gone by, we have seen less access to specialty care for indigent patients.)

So, he tells a story that is much too common - the uninsured often delay care until disease is advanced. If, indeed, his bleeding is caused by colorectal cancer, his chances of a cure have markedly diminished by this delay.

So, do we have a great "system?" This patient clearly tells me that he doesn't think so, and wonders how his life would be different if he had access to care that other countries provide.

This report from the Commonwealth Fund shows that our "grade" as a system in the US has fallen from 67 in 2006 to 65 today, largely due to the 16% increase in the number of working-age adults who are uninsured or underinsured. That's this patient.

And, what could I say to him on Monday? Well, we'll ask our colleagues in the community and region again if they can provide this diagnostic test for you at a reduced cost to you. All we can do is ask...

Stating the obvious...

I'm always amazed at medical studies which seem to state the obvious. And, I'm always wondering, "Who didn't know that"?

The most likely to elicit a response of "Duh" are the articles like "Childhood obesity linked to eating too much and not exercising enough." Gosh, that's all it would have taken for me to get published?

But, when it comes to healthcare policy, it becomes apparent that many of my friends and neighbors don't have the same experience of the needs in our community, and frankly don't believe that things are as difficult as they really are. That might be reflected in blaming the uninsured for being "lazy", or thinking that all Medicaid recipients are just "welfare moms", who will keep having kids so that the State will pay them more money. Or simply that the elderly Medicare patient can't be underserved; after all, they have insurance.

My favorite example of an unbelievable situation is that of the GAU system in our state. (If "favorite" is the right word ...) In our state, we have a public program to provide support for those who are disabled, referred to as "General Assistance for the Unemployable ". Well, that makes sense - if we have citizens who are unable to provide an income for themselves, I would argue that our rich society has an obligation to help them in meeting their daily needs.

But, listen to these words that one of my patients read on the letter which announces her enrollment:

We have decided that you are unable to work at this time based on Mental Health Disorder. ... You do not qualify for medical that covers mental health treatment and so, you must find a primary care doctor to help you explore possible medications for your mental health disability.

So, did you catch that? You are disabled. So, you deserve medical insurance coverage. But, we're providing you with insurance coverage which does not have the benefit of coverage for care for the condition which causes your disability. (And, then, goes on to suggest that your PCP just give it a whirl and see if he/she can help you, without benefit of specialty consultation, if indicated.) Incredible. But, true.