Wednesday, September 23, 2009

Health Care

There’s a calculus that’s going on in the minds of most insured Americans (the ones I talk to in my white urban professional upper middle class bubble, and the ones represented in plenty of coverage, whether or not reflective of real pluralities) that President Obama tried to speak to in his address to the nation, and it goes something like this (also, most doctors are doing this math from a more educated, and differently interested, position):

There’s X number of doctors in the U.S., and most of them work way beyond 9-5, five days/week. They already currently don’t give enough time to patients as it is. There’s Y number of people who currently have access to medical care. That number Y could as much as double (since most insurance is crummy anyway and people don’t have unlimited access now), but number X is staying right where it is. So the access of people who currently have insurance either has to be reduced, or the quality of the care they receive has to be reduced by longer waits between visits and less time with the doctor. This math doesn’t just have to be applied to doctors; it applies to MRI machines, operating rooms… these are limited resources. Currently, we ration these resources out by giving them to people with better jobs, better healthcare, some combination of the two, or people who have lived past 65, while people who aren’t in those categories die.

The proposal, as far as it’s been explained, is to ration out care on a basis that is blind to all but need. To people who are relatively healthy, with moderate complaints, this sounds like condemning them to discomfort with all but life-threatening illness, as doctors devote all their time to making sure no one dies.

President Obama’s answer to this concern was to imply that people who think they’re in the lucky insured category now will find themselves out of that category within the next couple of decades. But is there another way to suggest to people who work hard at good jobs that they can get a little bit of an edge over mythical welfare queens in getting their healthcare? Is there a way to convince doctors that they will be treating anything beyond life-threatening illness, that they’ll be able to pay attention to quality-of-life issues without bankrupting their offices or working themselves into an early grave? That they’ll have time for research, that their opinions as professionals will still be respected (as they are for patients who have private, non-HMO insurance)? That they’ll be able to pay off their college and medical school and internship/residency debt without having to live on a sofabed in a studio apartment like the drummer in a bad Chicago-area band?

Forget about the tax issues; people who have medical care want to keep getting their medical care. Unless the President’s proposal is to increase the number of nurses/nurse practitioners out there to fill the primary care role, which would have some of the same effects as increasing the numbers of doctors, people who have health care stand to lose quality of treatment if access is democratized… or good health care will be even more expensive than it is now, as all well-regarded medical providers move to a cash-only system and there’s no insurance for less-than-emergency/life-threatening conditions.

And that’s still what’s going to happen if you increase the number of doctors out there, because if you make it easier to be a doctor, you’ll end up with a lot of doctors who are, you know, stupider than the people who are currently doctors. This is also true if you reduce doctor compensation. A lot of people go into medicine for the salary, not the passion– and a lot of those people make great doctors right now, but will go into biotech research, or banking, or law, or something else lucrative instead.

So: Can you create a parallel system that provides basic care to currently uninsured individuals without putting them into the same system as the currently-insured, or without decreasing quality of care for those currently covered? Maybe. And that’s the program that will overcome a lot of the current opposition.

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