Health Care For All Americans, Part 3: UPDATED

Over the past few days, Dr. John and I have been having a fascinating discussion about this post from September 2008.  It is one of the first pieces I wrote for Extreme Thinkover,  before President Obama was elected, as well as at least a year before the serious work on what would become the Patient Protection and Affordable Care Act, known as “Obamacare” (but which I prefer to refer as “the ACA”) was being worked on.  It was also before Dr. John and I met and got acquainted.

I deliberately haven’t edited the post below, so our comments will make sense in the context in which they were written will make sense.  I think my readers will enjoy the back and forth between us, and I invite you to add your own comments, should you feel so inclined.

IMPORTANT: Read the comments starting from the bottom of the thread. It is where the discussion starts. And you may have to move up and down a few comments for our replies because of the way WordPress publishes them: by the time stamp of the comment/reply and not directly associated with a given submission.  Sorry for the inconvenience.


Health Care for All Americans: Part 3

In Parts 1 and 2,  I discussed first, the assumptions needed from a medical perspective, particularly with respect  to the scope of treatment plans that would lead to optimizing the health of Americans, and second, how those assumptions would create a radical transformation in the health of Americans that would work its way through all aspects of daily life.  In Part 3, I now want to describe the logic that shows how the country would benefit.

We’ll start using my first assumption: Preventable diseases are prevented.

We could use any number of examples, but the format of the blog does requires some brevity, rather than a detailed White Paper or journal article.  I also acknowledge that the ideas I  present here have all been suggested by others, but this is how I choose to organize them.

For purposes of our discussion let’s call our example citizen, Larry.  Larry works full time for minimum wage, does not have  health insurance, and cannot afford to buy private insurance.  He also does not qualify for any government health care benefits.  Larry’s wife also works for minimum wage, but only 24 hours per week.

As long as his health holds, Larry can work and he has no medical needs.  He pays local, federal and state taxes and uses no special government services.

But let’s say that Larry gets pneumonia.  It is a very common viral strain, and can be treated successfully with antibiotics, and could have been avoided entirely if Larry had had a pneumonia vaccination.  Now he’s faced with a dilemma.  At first he thinks he just has a chest cold and he can wait it out.  Being a conscientious worker, he toughs it out and goes to work, but exposes his coworkers to the bug through his worsening cough.

By the weekend, Larry is really sick.  Over the counter cough medicines provide almost no relief, and on top of that, his cough is becoming increasingly productive.  He cannot sleep because of the cough and not being able to find a position in bed where he can breathe without effort and  pain.  Larry knows he needs to see a doctor, but having no insurance, he does not have a primary care physician, so he has no idea who to call.  Finally his breathing becomes so difficult that his wife calls  911.  Larry is taken to an emergency room by ambulance, but one on the far side of the city because the hospital closest does not like to take patients without insurance.

By the time Larry gets to an emergency room that will accept him as a patient he is nearly in respiratory arrest.   The ER doctor quickly diagnoses the pneumonia, but that it is so advanced that Larry’s life is in danger.  She intubates him immediately and transfers him to the hospital’s intensive care unit. It is four days before Larry’s condition has improved enough to send him to a “step-down” unit and two more days before he can be admitted to a medical unit room, and he is discharged two days after that.

Larry is fortunate that the hospital he is at has Certified RN and MSW Care Managers.  They work with him and his wife throughout  the hospitalization, develop a treatment plan and a discharge plan, set Larry up with a local medical clinic that treats patients without insurance, and provide his wife with food  vouchers and bus tokens so she can make the long trip back and forth to the hospital.

Despite all this, when Larry is wheeled out to the taxi to take him home, he has a hospital bill that is $250,000.  Since Larry and his wife together make too much money to qualify for Medicare, that bill rests squarely on their shoulders. He has no way to pay it back.  He will not be strong enough to work for at least another three weeks.  He will have not earned a dollar since he got sick, and won’t until he returns to work.  His wife’s income is not sufficient to cover all their bills,  and if they pay the rent, they will not have enough money to buy food.  The hospital sent home a week’s supply of medications, but after that, he will have to pay for them himself, and due to the damage to his lungs, he will need regular medications for at least six months.  Those prescriptions will cost over $800 per month.  Through the free medical clinic he can apply for medication cost support , but that can take up to four weeks to be approved assuming he qualifies.

Now multiply this basic scenario by twenty or thirty million Larrys a year. Every year. That is health care in America.

Here’s what happens.  The only good news is that Larry has survived a brush with death, ironically from a completely preventable disease.

Larry and his wife now owe the hospital $250,000.  They have no assets.  Even though they signed a promissory note with the hospital, no one is under the illusion that he will be able to pay back more than a few thousand dollars if he is a very conscientious person.

Larry and his wife owe the ambulance service perhaps $3,000.  They cannot pay it, or they will have to try to pay it off in very small amounts per year at a probably high interest rate.

Larry will lose at least a month’s income, and perhaps more if his recovery is longer than expected.  If he is very fortunate, his employer will hold his job until he can return.  In the meantime, his wife’s income is not large enough to cover their essential bills, starting with rent and food.  If Larry’s wife cannot get more hours from her current work, her only realistic option is to get another part time job, likely at minimum wage.  Whether that will at least let them pay for their basics is not certain.  It is also uncertain how flexible their landlord will be to let them catch up with their current rent.

It should be clear by now, that one simple, preventable illness has created a cascade of events that affects the economy, are extraordinarily expensive and completely unnecessary.  Yet, this is the true consequence of the current American health care system.

The hospital will have to write off the $250,000.  To compensate they will have to pass this loss, as well as hundreds of others per year, to their patients with insurance.

The ambulance company will have to spend a lot to try and recover their fee from Larry, and will pass those added expenses along to their other customers who can pay, either privately or with insurance.  If Larry doesn’t keep up with the payments, they may turn him over to collection, which will damage his credit.

Larry’s employer loses productivity from a good worker.  The company may have to hire temporary labor to fill Larry’s absence, which will be more expensive.

Larry and his wife lose essential income, which at minimum wage is marginal to begin with, and may jeopardize their ability to even house and feed themselves.

Every day that Larry does not work means that his wages do not generate taxes, local, county and federal, as well as FICA withholdings.  Multiply that by twenty or thirty million Larrys year after year and the loss is well into billions.  The impact of this loss of tax revenue and productivity is staggering on the national economy.

All this from a preventable disease that could have been stopped before it was started if Larry had had access to the most basic medical care.  Everybody loses.  The nation is weakened through attrition in ways no external threat could impose on us.   This national “epidemic” is progressive, it is close to end-stage, and we could all too easily end up with a terminal prognosis.  We may reach a point that we literally will be too unhealthy to survive as a nation.

We still have a choice.  Until the epidemic takes that away.

22 thoughts on “Health Care For All Americans, Part 3: UPDATED

  1. In a way, yes; in a bigger way, no. Dr. Carson gave a very good speech. His address was civil and forthright. He clearly is a man who has a broad range of gifts and talents. However, the fact his video got over a million hits and that he is a neurosurgeon at Johns Hopkins does not meet the criteria for high profile influence that I maintain is lacking now, and was when the ACA was being crafted. I watched his entire address. It is fascinating that YouTube’s vids of similar topics generated a bunch of others, almost exclusively from conservatives, that crow about Dr. Carson having “slammed” Pres. Obama at the Prayer Breakfast–that term being used by Fox News. According to Hannity and Rush I am supposed to be deeply offended by Carson’s remarks. As usual, they are wrong.

    If Dr. Carson were to appear on the cover of “O” magazine or have a ninety minute interview with Barbara Walters, then I would say he has reached the level of notoriety that would give him the national exposure I find is currently lacking from the national physician cohort.

  2. I concur with your assessment of the AMA. But it begs the question, why was there not a national uprising among physicians that shoved the AMA out of the way and declared they would be a coalition that was going to sit at the table in framing the ACA? I contend this vacuum was filled by groups such as AHIP (American Health Insurance Plans), PhRMA (Pharmaceutical Research and Manufacturers of America), and other big-money medical-related interest groups, leaving the vast majority of the physicians in the country with no reliable voice. When you read the ACA, you can see their fingerprints on the final document, but as for the docs–woefully lacking.

  3. The “flaws” you have been pointing out reflect the talking points that those conservativies who want to repeal the ACA use on a regular basis. From my perspective it is a strategy of “death by a thousand cuts” or “one flaw invalidates the entire law” You have not presented what your overall position is on the ACA, or if you subsribe to the anti-ACA attacks demanding repeal that the Republicans in Congress have declared is their intention. So, what is your position on the ACA as it stands right now as the law of the land?

  4. Many physicians found the AMA’s behavior deplorable. I have never been a member.

  5. I wasn’t suggesting those three specific individuals, but rather holding them up as the kind of high-profile people that the medical community, particularly physicians, should have been grooming for negotiations that would lead to the Affordable Care Act. My contention is that a crucial historical opportunity was missed because the docs, on the national level, did not have their eyes on the ball when President, even candidate, Obama threw the first pitch in the health care reform ballgame. In other words the national physician community needed their equivalent of the NRA’s Wayne LaPierre. In short, they blew it. Instead groups like AHIP and PhARMA used their lobbying power, money and political clout to influence the form and structure of the ACA, and the docs were MIA. And look at the mess we ended up with. I was following the AMA through the months before and after Obama’s election. They impressed me as behaving like a combination of the good ol’ boy’s club in a 5 year old’s body whining and throwing tantrums while the real work was going on inside. I found their behavior deplorable understand the circumstances. I hold the belief that many of the ACA’s weaknesses are directly due to their lack of vision and leadership in the creation of the ACA.

  6. You keep talking about “scapping” ACA over flaws I am pointing out. Where have I ever said scrap the ACA in my recent comments? Strawman argument. I’m talking about what to do now, S/P Obama’s re-election. You yourself have claimed in the past we should try to fix the shortcomings of the law, yet you shoot down any ideas to improve it. Giving individuals the same tax treatment (or eliminating it for all) would be the fair thing to do, and reduce economic inefficiency. Doing this would also help people like Larry purchase insurance, which is mandated by law. So, DHHS and the IRS are saying, you are required to purchase health ins with govt-mandated bells and whistles (i.e. increased cost), but treats different people differently in terms of cost just by virtue of the fact that they don’t work for a big company or own their own business. Wouldn’t you like to fix this? Give poor Larry a fair shot and have him play by the same set of rules as other more fortunate patients.

  7. I doubt the media would treat any celebrity physician who did not agree with the liberal narrative with much respect. And you want a non-politician, non-activist physician, too? Many on the right would consider Dr. Gupta to be an activist. I’m not sure I agree with stuff I’ve heard from Dr. Oz from the medical standpoint.

    I have to disagree with you on this one, and the conditions you impose.

  8. The IRS has never written its rules so that everyone gets the same advantages. People who own homes can itemize deductions on their income tax even if they don’t make a lot of money. People who don’t own property cannot even though they may make as much annually as the home owner. Married people get to claim deductions that single people aren’t allowed to. The list goes on into the hundreds of rules. The fact that if you can’t file a Schedule C you can’t claim the same deduction as someone who does is just another IRS cross we must bear. But one should keep in mind those rules can be changed by Congress. Not this Congress, certainly, but it is theoretically possible. Again, scrapping the ACA based on an IRS rule defies logic, when the benefits accrued to society through the law as whole far outweighs that negative.

  9. These three doctors may be fine people, but none of them are household names. When I used the term champion, I was thinking of individuals like Dr. Joyce Brothers, Dr. Sanjay Gupta, Dr. Oz Mandel, for example, physicians who have risen to, in one respect, celebrity status, who have an established bully pulpit to advocate for the causes they support. The medical community should have been cultivating individuals such as these over the past decade so that when the health care legislation finally was placed on the front burner in Congress and the public’s awareness, they could naturally be leaders in the national dialogue that would transcend partisanship and be champions for the health of the American populace, not beholden to a political or interest group’s agenda. I view this as Medicine’s great failure that historians will wonder about for generations to come. In the end it may be that the hospitals were more influential than all of physicians combined. The Catholic Health Association was at the ACA table from the beginning; without its influence, the ACA might be far more flawed than it is.

  10. So, should individuals who do not file a Schedule C with the IRS have the same tax deduction for health insurance costs as people who purchase group health insurance? What ever happened to same set of rules?

  11. Again, these kind of technacalities miss the point of the post. If Larry had had an afforadble path to seeking medical help, the chances of his contracting the pneumonia would have been reduced, as a general rule of thumb. Apply this to 30 million people and you have over time, regardless of what their medical condition might be (and having that path, I would contend reinforces personal responsibility for one’s health) a healthier nation–with all the benefits that accrues to society at large.

  12. All right, I’ll concede the point on antibiotics, but my overall argument, I believe is still valid: America’s current health care system is broken so badly it disenfranchises in the neighborhood of 30 million people who are denied the equal opportunity to have the same access to health care that those who are fortunate enough to either have a health plan through their employer or have the resources to pay for their medical care. I would add that the medical community, in my opinion, has a direct responsibility to provide the leadership to reach out to those who do not have the advantages just listed as the most humane approach to their vow to be healers–which for better or worse, the citizens of the country believe they are. The technical “errors” you cite in my post are beside the point. From my perspective, since the outset of the initiative that led to the Affordable Care Act, the missing element was a critical mass of medical professionals who saw it as their responsibility to their patients and profession to ensure the best bill possible went through the legislative process. Instead, the medical community, including the AMA, appeared to be more concerned about protecting their turf and resisting any change that disturbed the status quo. Hence articles on topics like Health Care vs. Health Isurance. The average person really doesn’t care. He or she just wants to be able to go to the doctor when an illness or accident happens and not have to sell the house to pay for the care. This is the issue that I think the nation’s medical professionals were disastrously MIA. Without that leadership–can you name even one champion for health care reform who was not a politician or activist, who fought relentlessly for the needs of the patients and the highest quality for the profession–the ACA got cobbled together as such a political document (why, for example, does the ACA under the section that details the “Prohibition of Discrimination in Favor of Highly Compensated Individuals (Subtitle A, Sec. 2716) is there subsection preventing doctors or clinics from participating in any study that involves guns and violence (Subtitle A. Sec. 2716 (c) [1-5])? It has the NRA’s fingerprints all over it). Where were the champion physicians to ensure that kind of irrelevant hogwash never made it out of committee? The medical community needs to stop grousing about the ACA and step up to craft it into the kind of law it should have been in the first place.

  13. Herd immunity isn’t relevant for community-acquired pneumonia, only a fraction of which is due to Strep. pneumo., which also isn’t nearly as contagious as influenza. There is no vaccine for the vast majority of community-acquired pneumonia.

    By adding that Larry was a smoker to the vignette, I made him a candidate for the pneumonia vaccine, since you implied he was less than Medicare age when you stated he had no health insurance.

    Do they treat viral pneumonia with antibiotics in the U.K.? I thought that was only something noctors did here in the U.S. I would also add that in the vast majority of cases, no causative organism is found that caused the pneumonia, and treatment is empiric.

  14. The efficacy of the pneumonia vaccine in the broadest sense is not the issue. I now that you are an advocate for “herd immunity” and you would, in fact, give Larry a pneumonia shot if you decided it was medically appropriate. The issue is that neither Larry nor his wife had any medical insurance, so they did not or could not take advantage of getting the pneumonia shot to begin with. But what lies behind that is more important: since they have no regular medical care or routine accecess to a physician, they make medical decisions not based on the medical community’s perspectives and paradigms, but avoid going to the doctor as a matter of resignation to their situation and their resentment toward the medical system in general. Patients share that frustration and anger with me on a fairly regular basis. Perhaps it is different in Illinois, but that is the situation here in Oregon. Our emergency rooms this time of year are frequented by people with no insurance who have pneumonia or have developed it as a complication of another respiratory disease (such as influenza because they didn’t have the money to get a flu shot).

    Ambulance policies vary a great deal. In my community the medics ask the pt which of the three emergency rooms he or she would like to be transported to. Depending on the distance and the amount of care required enroute, the charges are $1400-$2500. I assumed in larger metropolitan areas, the charges might be as much as $3000.00

    I wrote this post long before my mother became ill and died after a 23 day stay in an intensive care unit. Based on the out of pocket expenses we had to pay, and extrapolating what her better-than-average insurance paid in addition to her Medicare coverage, we estimated her bill to be at least $1.5 million! Had she not had the insurance and medicare combination, as her power of attorney, in Oregon I would have been been responsible for paying the entire amount. That is not a happy thought.

    I stand by what I wrote. I understand that medicine reduces the risk only to a certain point, but I continue to contend that the behavioral habits of people do not match the “reasonable patient” paradigm that so many doctors appear to hold. Essentially, people do not make rational decisions regarding their health care, and that in our deeply broken system , in my opinion, the medical professionals all too often could be characterized as being enablers of this social disaster. It’s not just all about cost containment, ICD coding and reimbursement schedules.

    P.S., There’s is nothing in the scenario that states Larry smoked.

  15. “But let’s say that Larry gets pneumonia. It is a very common viral strain, and can be treated successfully with antibiotics, and could have been avoided entirely if Larry had had a pneumonia vaccination.”

    Strep. pneumo. resistance to amoxicillin is quite prevalent, and amoxicillin alone is not appropriate treatment in the U.S. for community-acquired pneumonia. (see Table 7). Amoxicillin may be cheap and generic, and it’s use expected in the U.K.’s socialized medical system. But it is very hard to justify it’s use to a plaintiff’s lawyer and jury in court if the patient suffers complications (e.g. respiratory failure, sepsis) or dies. A macrolide is a better first-line choice, assuming the prevalence of resistant organisms is low in the community. Bigger guns can be reserved for older, sicker, and patients with risk factors.

  16. Pneumonia vaccines are far from 100% effective.
    Many other viral and bacterial organisms cause pneumonia for which there are no vaccines.
    And it is only indicated for elderly (i.e. Medicare-age) or high-risk patients.

    At least in IL, the ambulance does take the patient to the nearest hospital capable of handling the case (e.g. What level trauma?).

    $250K is an exaggeration for this hospitalization. The point is well-taken that medical care is expensive and can ruin someone financially.

    The basis premise that this illness was preventable is incorrect. The best the medical system can do is reduce risk. Besides a health care system where everybody has a “fair shot,” personal responsibility plays a role too. Perhaps if Larry didn’t smoke, he wouldn’t have gotten sick, nor required months of respiratory medications after the bacterial pneumonia was treated with the antibiotics.

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