a healthcare question

a friend recently asked how i reconcile the idea of accessible health care with the abuse of emergency rooms. my not-so-short answer is copied below, because it took a long time to write.


The longer answer is that the abuse of emergency room services (which is absolutely a problem everywhere, and especially in teaching hospitals) is a symptom of the inaccessibility of health care. In reality, its just the tip of the iceberg.

The first thing to grasp is the number of Americans without insurance. Basically there are a huge swath of people that have no assistance in health care. Depending on the state, VERY low income people (maybe those at 100-150% of the poverty line, which you know is very poor) will have coverage through some social services. This generally applies to women, or people with disabilities, maybe to single fathers, but definitely isn't universal. And people with good jobs and benefits will have coverage through their employers or may be able to buy their own coverage (though at much raised cost). That leaves a huge number (somewhere around 50 million Americans) that have no coverage.

People without insurance generally can't afford the expense of routine preventive well-visit care (primary care). Usually, they won't be able to afford even basic sick visits or a trip to the doctor until their health is very bad and their problems well past the point of easy (and cheap) interventions. (This could mean just that their respiratory infections are much harder to treat, or that their cancer is several stages progressed by the time they're diagnosed.) People coming into the ER with a headache sounds ridiculous, of course, but the ER is often the only option available without a $100 price tag. And people have a right to care, and headaches get old after a while. So the people that flood ERs with hangnails may be a problem, but they are the less heartbreaking of stories, at least.

If we actually had accessible health care for everyone, the people flooding the ERs would have access to preventive medicine services, in the form of a general practitioner. These practitioners would be paid for in some way (pick your candidate's health care plan) that would cushion the individual from the full cost. As for Obama, he's advocating an affordable insurance program that would open the federal insurance pool up to everyone. And the SCHIP bill that thank God just passed expands coverage to all children without insurance. I'm an advocate of moving completely away from private insurance companies, because I think they too often neglect care for the sake of the bottom line. At the very least there needs to be a viable public option (in the way that education provides a public/private choice).

The other important issue to consider is that the prices paid and charged by hospitals and private doctors are completely artificial, and are unfair to people trying to pay out of pocket. If you stay in a hospital and look at your itemized bill, you'll see ridiculous prices for aspirin because the hospital is using their relationship with insurance companies to recoup cash lost elsewhere. If you are paying for services and are not the state or an insurance company, you're getting screwed because the system was not designed for you to be the payer. This is another smack in the face of the uninsured (and underinsured). I won't go into the pharmaceutical industry, but again, the prices aren't fair here for the individual payer.

The creme de la creme of this problem (and the as yet undiscussed) is that very few medical students actually want to be general practitioners. They all want to specialize, because our current health care system rewards specialists with the big bucks and treats GPs like volunteers. An effective revamping of the health care system is going to require redistributing compensation for doctors or finding a way to entice more doctors to pursue being a physician rather than a cardiologist. In Massachusetts, where they granted by state law universal health care, this issue has been their biggest problem, and I'm crossing my fingers it will be addressed in Obama's plan.

If I may take it one step further, I'll point to the fact that medical students are driven to hunt down the big bucks because medical school is far too expensive. The requirements to admission already cater drastically to the affluent, but the cost of medical school itself is a deterrent to future doctors becoming general practitioners. I'll step towards the socialist line and argue that there is an important place for public support of medical schools and students.

I'll stop there. The basic point for me is that health in the United States is now treated as a business. Its a right only in the extreme, final case (life or death). This is a travesty; health care is a right and needs to be provided. There are many, many examples of health care systems from around the globe - each with their own problems, of course, but none as wasteful and slipshod as ours.