Tuesday, March 23, 2010

Reader Dissent

A reader named "J" wrote a comment on my post supporting health care reform from last week that I thought would be enlightening to re-post in full:
Buckeye, I'm surprised at this post. After all, not too long ago, you had a well-timed post against your being taxed at an unreasonable rate (see "Welcome to the Real World"). Why the change of heart? An additional tax on those making $200,000 and more, reduced Medicare reimbursements, new, expanded Medicaid obligations in state budgets, a 40% tax on existing "good" medical plans, new excise taxes on tanning salons, pharmaceutical companies, device manufacturers, and health insurers (ultimately passed on to the end users). Buckeye, if any significant amount of your business is Medicare, your reimbursements are going down while your taxes go up.

This bill proposes a shotgun fix in the wake of a majority in both houses of Congress and the midterm elections. This is not a problem that can be solved by this bill. The American Academy of Family Physicians predicts a 40,000 shortage of their own pedigree by 2020. Let's consider the numbers further: it takes at least 7 years to train a physician. Our current physicians are expected to take on 32 million new customers by 2014. Nurse practitioners and PAs are looking to fill this gap in care, making doctors in primary care less relevant. In fact, nurse practitioner programs are transitioning to offering only doctoral programs to "be on the same parity of respect with doctors." Nurse anesthetists on average now earn more than the average family practitioner.

The mandate for insurance has few teeth. For an individual, a $95 penalty in 2014 increasing to $695 by 2016. Is there a health plan that costs $695 a year? Guaranteed issue of health insurance only works with enough payees, and this penalty is not exactly an incentive to purchase a policy.

The solutions are not pretty, but when taken in small doses, like sips of alkaselzer, you have measurable progress. First, fund more residency positions in primary care to take on the additional patients. Then implement guaranteed issue of health insurance with a stronger purchase mandate. Leave the feds out of modifying health premiums, otherwise every federal official will run on lower health premiums without regard to solvency. Allow states to recover if adopting the unfunded mandate of expanded Medicaid eligibility and greater reimbursements. Oh, and what about tort reform?

J's points are well taken. There's no doubt that health care reform, in its present iteration, will not be a financial bonanza for physicians. It will alter our income expectations for the next several generations. We'll pay more taxes. Reimbursements will steadily decline (how do you think this bill will be able to maintain any illusion of fiscal sanity?). There's no tort reform (other than $50 million set aside for the study of undefined "pilot projects"). There's nothing in it to permanently address the medicare SGR cuts. Subsidies for medical school education and financial incentives to entice medical students into choosing primary care are curiously absent. There was no special interest group involved in this year's long HCR debate who came away from the final deal with less than us physicians. We got hosed. Some of it is our own fault. We're a disjointed, politically diverse group of professionals. Furthermore, our big lobbying arm (the AMA) proved itself to be an impotent, ineffectual voice at the bargaining table. What's done is done.

So why do I still support the passage of Obamacare? This is going to sound awfully pretentious, but I can't help it--- the moral argument for reform, any sort of reform, is just too powerful. Basic health care ought not to be dependent on market cycles or employment or whether or not you have a pre-existent disease. Americans ought to be able to go the hospital, see the doctor and not worry that the treatment they receive could potentially lead to financial ruin. It's just not right. I have a young patient right now who is going to benefit enormously from the passage of the bill. She's a 21 year old physics major who wants to go to grad school and eventually teach at her local community college. A few months ago, she presented to the hospital with free air and peritonitis. She had perforated her colon, secondary to what ultimately was determined to be Crohn's disease. She has a colostomy and wants to have it reversed as soon as possible. Her health insurance through her mom is due to run out in May. But with the passage of the bill, she can stay on her mom's plan until she's 26. We don't have to rush the colostomy reversal surgery. We can take our time. Make sure she's completely healed. Furthermore, let's say she gets that PhD in physics in a few years but she doesn't score a job right away. Maybe she teaches for a year or two at a private high school on a contingency basis, without benefits. How is she going to buy her own health insurance as an individual? She has Crohn's disease! Who would insure her?

Closer to home, my own mother lost her job at Akron Children's Hospital last year. She'd worked there 25 years. She's not quite old enough to qualify for Medicare. Her COBRA plan runs out in the fall. What is someone like her supposed to do?

We have to help each other out, dammit. It's more than tax brackets and socialism and redistribution of wealth. This is health care. It's life. It's the people around us, the ones we love.

Is it a perfect plan? Hell no. But it would be more useful to look at it as a stepping stone to something better. What I'm hoping is that the Republican Party uses this perceived defeat as motivation to renounce their heretofore obstructionist, denialist stance and get off their asses to propose additional reforms. The GOP hates Obamacare. That's been clear enough for a year. So do something about it! Add to it. Make it better. Get tort reform in there. Do something about the primary care/general surgeon shortage and medical school debt. This HCR bill is a paragon of centrist principles. There's no single payor. This is not government takeover. It isn't anything like what the noise machines on Fox and Rush Limbaugh would have you believe. It's simply an initial foray into a more just society...

David Frum (conservative pundit, American Enterprise Institute fellow) has a nice piece on CNN articulating a possible GOP game plan in response to the passage of Obamacare.


Anonymous said...

i wish there was some way to project this blog post into the brain of every politician in the country.

This was a start, maybe not a good start, but a start. The bill needs a sharper stick (higher penalty for no insurance) and a better carrot for doctors (tort reform, reimbursement protection or a way to reduce med school debt.)

the GOP is paralyzed by their insane rhetoric. They can't come to the table and act like a adults now that they have already started slinging the mash potatoes around.

boz said...

I agree with what you say. From a morality point of view this the right thing to do. But as a final year premed student starting med school in the fall I am worried for school debt and future income. Needless to say, I am not considering primary care right now. It's sad but it is the reality of the situation right now.

Brian and Jennifer said...

See, I'm like you. Fundamentally torn.

I'm an ER doc (as mentioned previously on some other posts). I went into my job because I love the fact that I can take care of anyone, and everything, regardless of the circumstances. I don't ask for payment first, and refuse if they can't pay. I just treat disease and whatnot...(and I know that's kind of naive at it's root, but it's really the truth. I don't care who can pay and who can't. It's not my job. My job is to treat).

I am glad that everyone's going to have the opportunity to have 'health care' and 'insurance'. But my major beef with the whole thing is that a) it does absolutely nothing significant to deal with tort reform, b) that while it does increase coverage, it does absolutely nothing to increase access, and c) it does nothing to encourage people to go into primary care (of which is of direct importance, as my wife is your average, garden variety office based pediatrician).

Take Massachusetts for example. They have 'universal coverage' style health care, but there is a significant problem because they didn't expand access. There's just simply not enough doctors to see the number of patients in the state that need care. That's a huge issue because as you need more docs, and you don't have access, where do the patients ultimately filter down to? The ED, naturally.

Secondly, the bill does nothing to really address cost control. I know it mentions things about 'bundling care', but is that really the answer? I asked my wife last night if she knew how much a cardiothoracic surgeon makes for your run of the mill CABG. I even told her that Medicare payed the hospital a grand total of about 65,000$ per operation. Her answer: 20,000$. I informed her that it's actually between 2000 and 3000 dollars for the operation, and that included the post op period, all the visits, and any other problems that are incurred in the post-op period. The rest goes to meds, the OR time, ICU time, the critical care monitoring, etc. Bundling isn't the answer. Price transparency is the answer. Let people know the prices of what it costs to have things done. And be transparent about it. Don't say it costs X amount if you have insurance, and Y amount if you're a self pay. There shouldn't be a discrepancy on prices for the uninsured. And that's where a major source of the trouble is. The prices need to be fixed whether you are insured or not. And if Hospital A has a lower price than Hospital B, then you should be free to choose what hospital you can go to that can control your costs as much as possible. But there is nothing to address that.

Thirdly, where is pharmaceutical reform? How much does your dose of Zofran cost? I think I heard a generic Zofran ODT actually costs like 19 cents. But how much does a pharmacy charge per pill? 10 bucks? That's ludicrous.

Until some of these issues get worked out, ensuring insurance for all does nothing to solve the problem except overburden a system that's stretched to the gills to begin with.

rlbates said...

Buckeye, this is similar to what I have been saying to my husband the past few days. He is hung up on the mostly negative parts of the bill, while I want to focus on the 21 yo physics student you just described. It isn't perfect, but it is a start.

Anonymous said...

I'm sympathetic to the school debt issue that Boz raises. Since we need more primary care physicians and it costs so much to go to medical school, it just makes sense for us to start a program under which a significant portion of their debt is paid by the government. Perhaps raise the funds by a tax on orthopedic surgeons, plastic surgeons, and other doctors who are very highly compensated.

As to this post, thank you Buckeye Surgeon for continuing to frame this as a moral issue and not just a financial one.

I fully realize that despite my great corporate group medical insurance provided by my employer, my primary care physician is going to be swamped and it will not be as easy to get in to see her.

But I also know that the current system is grossly unfair - particularly to those people who don't have college degrees and don't work for big companies with good group plans. Very few of the jobs available to those without advanced degrees are unionized, so too many of those people go uninsured and die early as a result.

It's also grossly unfair for those who try to run small businesses and who, like your mom, have lost their jobs and affordable health insurance.

Anonymous said...

And not all union insurance is great. I've had to wait 2 years to get covered for a pre-existing condition that's just gotten worse in the meantime. Will cost them more in surgeries now. But I don't make enough to afford the time off for recovery from surgeries so I'm still screwed. And the coverage isn't that great. Won't be able to afford the better meds.

Sergiu said...

I've read the post and all the comments and I can't identify with what you guys been feeling.
Here were I live, universal coverage health care has been available to everyone that has contributed with at least 1 cent in his/her entire life. So I can't even try to comprehend some of the fears the average American is having every single day through his life, to even try to reason how many existences are affected.
I hope though that the reform will brighten up the lives of the ones that needed it the most. Those without any form of health care coverage.
My prayers be with you all.

Anonymous said...

Buckeye - couldn't agree with you more. I'm two years away from finishing surgery training. Frustrated that tort reform, medical school debt weren't seriously addressed. Worried about how my reimbursement will be in 10, 20 years. A bit nervous about covering 34 million new peeps without a clear plan for cost control. Having said that --I'm proud as hell that Obama got this legislation passed. It's just unfathomable that we could continue to treat 10% of our population like they their health isn't as important as everyone elses. One of the Democratic congressman said it best - this bill is about justice. It ain't perfect but it's a helluvalot better than what we've got right now. It's incredible that Obama et al got this done. We should all be proud as a country. I've got college buddies, family members, colleagues, etc who are hard-working, honest people, and are uninsured because they can't afford insurance. They deserve better. And they're hopefully going to get it.

Anonymous said...
This comment has been removed by a blog administrator.
ParatrooperJJ said...

Unfortunatly your student is still not going to be able to afford an individual policy. I expect premiums to triple easily.

Jeffrey Parks MD FACS said...

Keep your borderline racist comments confoned to sites like Hot Air and Michelle Malkin.

jj said...

I keep hearing people talk about how we're going to need more doctors to treat the 34M new patients... That completely ignores the fact that those 34M people are getting treated now. Not by PCPs, but by the ED.

Seems there is a law of conservation of medical providers here that is being ignored. Yes, there may be (and hopefully will be) a dislocation of ED providers into primary care. But it's not like they don't have most of the primary care skills already.

Factor in the fact that managing chronic conditions in the ED is pretty wasteful, and we may need even fewer docs in total.

You (Providers in general) should be happy about the reduction in waste - using the proper providers for the proper care.

Nurse To Doc said...

I loved this post!

I am a British final year medical student (If I have passed my finals, I will be a doctor this time next week OMFG!)

Our NHS is crucified by public and politicans every day but even with it's problems, the bottom line is that patients get the treatment they need whether they are prince or paupers.

I think it's amazing that you are heading the same way.

Anonymous said...

Frum was fired for the column you linked to. Such a shame.


Anonymous said...

FA Hayek's book Road to Serfdom in real life. What does Britian and the United States have in common? Both countries are dead broke. KEEP THE MONEY PRINTING PRESSES ROLLING!

Victor Lazaron said...

Nice post.

I am another general surgeon in private practice who completely agrees with your thoughts here.

The moral argument in favor of national financial support of health care costs is simply too strong to ignore.

The actual bill is remarkably centrist, all things considered. The strongest argument against it - it takes from medicare funding to provide subsidies for the newly insured - is actually an argument in favor if it as far as I am concerned. I personally think it should be scandalous that we provide strong medical coverage to the elderly and, up until recently, little for children and nothing for young adults.

If I were designing a national health insurance system with the explicit instruction that I could not cover everyone and must divide into age-based groups, I would first insure children, then young adults - first parents of children, then others - and lastly the elderly. Why? Two reasons: 1. Productivity. Healthcare for the young can be seen as an investment in the future. Healthcare for the elderly cannot. 2. Healthcare for the elderly is an expected part of life. We should put aside for it, because we are all going to have to face it - just like retirement savings. Healthcare for the young is more of a crapshoot. Financing it really is health "insurance". And nearly no one could reasonably be expected to put aside money for an appendectomy or a car crash.

Does this mean I want to pull the plug on Grandma like Sarah Palin says? Heck no, the US is an incredibly wealthy country. We can easily leave Grandma fully plugged in and still have money for Ma and Daughter as well.

Anyway, I am pleased that I am not the only surgeon in the entire country who thinks that "Obamacare" is not the coming of the end of times.