THE GREAT AMERICAN Health Care Debate of the 1990's was doomed to failure before it began. By asking the wrong questions, we were destined to arrive at the wrong answers. The sad fact is that with all the changes and innovations of the last decade we have achieved no substantive improvements in public satisfaction, in effective use of our health care dollars, or in measurable health statistics.
In my roles as both an Emergency Medicine physician and a member of the Maryland General Assembly, I am all too familiar with the inadequacies of the current system. Let me relate three examples of the frustration and irrationality faced by all of us who are interested in America's health.
When 2-year-old Justin awakened after midnight screaming in pain, his parents rushed him to the E.R., where I diagnosed a middle-ear infection and prescribed a course of antibiotics and pediatric pain medication. Justin's records revealed a history of chronic upper respiratory problems and ear infections dating back to his infancy.
Both of Justin's parents are smokers, accounting between them for some four packs a day. The constant irritation of second-hand smoke made it that much harder for their son to shake off his perpetually stuffy nose and scratchy throat. I explained to the parents that although prescription medicines would address Justin's immediate problem, they could benefit his health far more profoundly by making their home a smoke-free environment.
The hospital's billing service and the family's HMO will spend the next six months haggling over the $45 hospital fee. Of course there will be no reimbursement for the second-hand smoke discussion -- despite the fact that it was the only portion of the visit with the potential to improve Justin's health over the long term, as well as to lower costs. There's no insurance code for it; so, in the health care universe, it doesn't exist.
Sick care, not health care
Doris, a constituent in my district, calls me with a problem concerning her health insurance. Suffering from osteoporosis (thinning of the bones caused by aging), she tried to obtain coverage for recommended preventive steps such as calcium supplements, an exercise program and safety rails in her home to prevent a fall.
Her insurance company told her that should she fall and break her hip; they will pay the hospital bill. But prevention is not included in the program. Doris can't understand why the system is willing to pay thousands of dollars in "sick care" for surgery, anesthesia, hospital stay and rehabilitation, but not the few hundred dollars it would take to help her prevent such a painful catastrophe.
Benefits like the ones Doris seeks are generally available in health plans only after legislative action "mandates" their inclusion.
Bad medical decisions made in corporate boardrooms raise public outcries that lead to micro-management by legislatures. Recent examples include 48-hour stays for new mothers or inpatient care for mastectomy patients. Such mandates are almost always resisted by insurance companies, managed care groups and the chambers of commerce.
Business owners, concerned about rising health insurance costs, respond by cutting benefits, hiring more part-timers and independent contractors. Families lose long-standing relationships with valued providers. The results of this roundabout process are piecemeal, inefficient and usurp decisions better made by patients and their chosen caregivers.
Portrait of despair
Cindy came to the Emergency Room because of a painful abscess on her forearm. Her needle-tracks and bruises -- and her arrest record for prostitution and shoplifting -- confirm that this 22-year-old woman is a heroin addict.
During the unpleasant process of incising and draining the pus-filled abscess, Cindy breaks down and starts to talk.
"I want to get off drugs, Doc. Can you get me into a program?"
Given the moment's potential, the desperate resolution in her tear-choked voice, I wish I could take her down the hall to a counselor who would begin the intake procedures and start her re-hab that very night.
But there is no counselor and there is no program, so instead I give her a phone number to call in the morning. If she's lucky, she might find an opening in a program three months from now. But to an addict, whose time frame is the four hours until the next fix, three months might as well be three decades.
It is estimated that 80 percent of robberies and burglaries are committed by addicts supporting their habits, and this doesn't include the drug component in such crimes as homicide, rape, prostitution and domestic violence -- or the ancillary damage to families of both victims and criminals.
A recent California study found the cost of putting an addict in drug treatment pays for itself many times over in savings on prisons, medical bills and crime losses. Yet treatment programs are under-funded and understaffed, incapable of meeting the rising demand for their services.