Through the Looking Glass: The Health Care Debate from a Doctor’s Perspective

We’ve all spent a good deal of time here at the League going over the various perspectives of the US health care debate and, indeed, many of us have brought some useful insights to bear on the discussion. However, I thought it might be helpful and interesting to get some thoughts from someone who works directly in and with the health care system on a day-to-day basis.

Luckily, it just so happens that one of the League’s Guest Authors and blogger in his own right (check out: Bleakonomy), Dan Summers, is an MD and was willing to engage in a back and forth with me over email about various facets of the debate.

As someone who works within the system on a day-to-day basis, what are your thoughts about the current state of health care in the US?

I think the current state of US health care is precarious.

For many people, it seems to be working just fine.  For many other people, they think that it’s working just fine until they come upon some kind of significant health care expense.  Suddenly, the insurance they thought was so good is revealed to be riddled with exceptions and inscrutable processes, and care they had thought would be covered is not.  We’re often left in the unenviable position of recommending or ordering care that is simply out of reach for patients, even if they are insured and have been paying premiums for years.

Then there are families who have lost jobs, which is a significant problem in an economically depressed state like Maine.  I can’t tell you how many times I have had patients who have been taking medication for years that they suddenly can no longer afford because a parent has lost the job that provided the insurance that paid for it.  It’s immensely frustrating.

There are others whose employers don’t provide insurance, and who make too much for public insurance but not enough to afford to purchase a private plan.  Even the costs of routine childhood preventive care can be daunting if you’re faced with paying them all out of pocket.

There is, of course, a flip side, which is that people often come in seeking expensive tests or medications that they don’t need, and people who are on public insurance (and thus incur no health care costs out of pocket at all) who come in repeatedly for frivolous reasons, or who treat the ER as an urgent care clinic because they don’t care to wait for an appointment in the morning, so even an unrepentant bleeding heart like me is given pause from time to time.

Again, from the perspective of a doctor working within the system, what is the most badly needed reform to the system itself?

I think the single most badly needed reform is a reform of private insurance.

I think there must be far greater transparency in what people are paying for, what services are covered, why certain services are not covered, and how decisions are made in general. Far too often, people get denial notices, and they are faced with fighting against a faceless, inaccessible corporate structure that evinces no interest in actually paying for their health care.

Along the same lines, pre-existing condition exemptions to payment for care have got to go.  Every so often, I will get paperwork from some insurance carrier or another, asking for information about whether a patient had some diagnosis or another before a specified date.  The conditions range from the complicated to the incredibly common.  (It’s amazing how often those forms get misplaced before I have a chance to mail them back.)

The fact that the insurance industry can refuse to pay for any recurrent or chronic condition if the diagnosis is made at the “wrong” time is appalling, and traps many people in jobs they can’t stand because they know they’ll lose coverage if they have to change insurance carriers.

Does that kind of reform seem possible without a public option on the table?

I don’t want to imply a greater degree of policy expertise than I have, but I must admit to being quite skeptical.

I think health care co-ops sound like a good idea per se, but I have a hard time envisioning them providing the kind of widespread alternative to private insurance that would be necessary to effect real reform.  Unless there’s a plausible alternative to private insurance, and one that’s motivated by considerations other than profit, I don’t see how effective attempts at reform can be.

The public option has the added benefit of covering people who can’t get insurance through an employer, assuming that it’s priced at an affordable level.

As someone who provides the health care that people receive, how do you take the argument provided by many opponents to a public option that such reform would suck the wind out of the private industry and effectively stall any real innovation in health care?

I don’t buy it.  (I know Megan McArdle, for one, has based a lot of her opposition to health care reform on this idea.)

First of all, there is a great degree of health care innovation that comes from the UK and France, and I think it’s perplexing to hold forth that only the American private sector provides a decent engine for innovation.

Now, obviously, the pharmaceutic industry doesn’t create new medications out of an abiding love for humanity.  Clearly the profit motive plays a major role in advancing medical technology and treatment.  But it’s not as though the private insurance industry is falling all over itself to pay for new medications or treatments.  Rather, they do everything they can to get patients on the cheapest alternative possible.  (For the record, this is not necessarily a bad thing, since older medications or treatments are often just as good or better than newer, fancier ones.)

I don’t see how a public option, even if it can negotiate for lower prices better than private payers (which I doubt), would cut pharma profits so much that they simply decide to stop innovating.

Another argument against a public option is that while it provides for equality of access to care, that it also forces a mono-culture of care that can’t adjust to the shifting needs of Americans from state-to-state, town-to-town, and case-to-case. As an MD who expresses some degree of support for a public option what are your thoughts on this challenge?

I find the premise of the question hilarious.  Private insurance companies provide absolutely none of the supposed nuanced approach to individual care that opponents would be implying with this objection.

Here in Maine, the largest insurer is Anthem, which is the very epitome of a monolithic entity imposing its will without regard to varying locales or individual cases.  (This isn’t to single Anthem out.  They’re all this way.)  There’s no reason to think that a public option would be any less responsive to shifting needs than a gigantic national corporation.

Do you see specific advantages that a system of private insurance provides over  public insurance?

Generally speaking, it is easier to get patients in to see specialists for referral if they have private insurance.  Many providers of specialty care won’t accept Medicaid, so there is often a long waiting period to get those patients seen.  (This is especially daunting with regard to dentistry.)  I think much of that has to do with inefficiencies in how Maine’s particular Medicaid program has been administered, with a significant history of delay for payment.

As I alluded earlier, because there is no out-of-pocket expense, there is a certain population of publicly insured patients who tend to over utilize the medical system for complaints that don’t really require attention.  They also often go to the ER if they don’t care to wait for an appointment.  (There are, I’m sure, plenty of privately insured patients who make similar decisions, but I think having to kick in a copay has a inhibiting effect for many people.)

Finally, it seems as though the health care reform debate has gotten a bit out of touch with reality over the last few weeks and has become more a political debate than a debate about issues and substance. As a doctor, what is one thing you would like to see people bear more prominently in mind when discussing/debating health care in America?

This is not simply an abstract debate about policy outcomes.  There are real, suffering people who form the basis for this debate.

It is a terrible, terrible feeling to provide care for people knowing that they don’t know how they will pay for the care you’re delivering.  (I cannot simply charge less for uninsured patients, as that would constitute insurance fraud.)  I hate practicing in a system where health care has become so blatantly commodified.

At the end of the day, I care about health care reform because I don’t want my patients or their parents to have to decide between accessing care they need and having money to pay for the other necessities of life.  It’s an impossibly corny answer to the question, but it is, regardless, still the truest one.

Editorial Endnote: I think it is obvious that both Dan and I have a bias towards the inclusion of a public option for health care reform, so if anyone feels like we wound up giving private insurance short shrift I probably wouldn’t be inclined to disagree with you. I think we did explore why it is that we lean towards the public option via Dan’s experiences as a practicing MD and I think it is useful to have folks of my and Dan’s persuasion offering unabashed explorations of that option on the site to level the blogging playing field.

Of course, opponents to a public option are encourage to make their points in the comments where the conversation should and no doubt will continue.

My sincerest thanks to Dan for taking the time to engage in the interview with me.

Tagged as: Health Care Reform, public option