Wednesday, July 29, 2009


As a postprandial no-show affords a little time for reflection after a hectic morning, I think about all the folks I see in this clinic, one after another until they become a blur, who are indigent, unemployed, and unable to obtain Medicaid or Medicare. This is rationing. We already ration health care, and this is how we do it, by the vicissitudes of finances and the job market.

Yes, they are seeing me, but they are very limited in their access to medications, psychotherapy, and other specialized services, such as psychological testing or substance abuse treatment. This is rationing, merely done haphazardly.

I suppose the health care mess boils down to two issues: social justice, and living within our means. Part of social justice is protecting the minority against the majority, always a challenge, by definition, in a democracy. Word is that resistance to reforming health care is growing, and Obama may fail in this as Clinton did. Why? Because most people still have health insurance and are more or less content with their coverage; they don't want to risk this in order to cover the uninsured. They enjoy seeing doctors who can bar no expense in arranging for testing and treatment. Social justice?

The perpetual refrain these days, from economists and myriad other experts, is that we can't go on this way, that is, spending a massive amount of GDP for medical results that, while spectacular in isolated cases, are merely mediocre on average. But if we are spending medically beyond our means, it appears that the public is not willing to stop yet. Perhaps we have not yet hit rock bottom; perhaps the system is rotting but not yet rotten enough. Perhaps reform is not possible until one or more of three things happens: the majority of people are actually uninsured, the majority of people are personally dissatisfied with the system, or the out-of-control medical-industrial complex really does throw the general economy into chaos.

I'm not an expert, so hopefully I'm wrong.


Dr X said...

Oh, yeah, glad to see you venturing into the political arena a bit.

Dr X said...

What worries me is that we will create a mess that will take 10 years to understand and 20 more years to unravel. And yet, the problems with health care are only escalating as we do nothing.

Part of the difficulty is that half of America believes firmly that it is impossible for any government entity to do anything competently other than imprison and kill people. Government employees are shiftless, evil sponges until you give them a gun. Then they are idols. (Maybe doctors should carry guns and shoot people who make them angry. That might just garner more support for a public option). We demand nothing from politicians because we expect nothing.

More seriously, though, the other part of the problem is that politicians are so dependent on private money, that government programs become hopelessly polluted by private interests by the time every congressperson has had their say. The bigger the program, the more larded with favors the legislation.

I do believe that a public option of some sort can work, but it will be tough for an American congress to pull it off. I think the French do it and they do it well for half of what it costs us per person. They have public insurance, not socialized medicine. Medicine is still in private hands.

But, God knows, you can't suggest that we look at what other countries do. American exceptionalism is such a given, that it is forbidden to publicly suggest that we learn anything from foreign people who are doing something well--especially if they're French. Well... I guess it's still permissible to ask them for cooking advice, but that's about it.

Novalis said...

I didn't even mention the fact that in many cases a major factor in their needing to see me in the first place is distress over general medical conditions that they can't afford to have treated.

Interesting point--I hadn't thought about the unique virtue (and efficiency) of (gun-wielding) government employees. With a holster in my belt, there would be no need to wait for patients to take the hint that their time is UP--until next month at least. (Happiness is a warm gun after all).

As you say, the American system may be wasteful and unjust, but it is OUR unjust and wasteful system, and we don't need to be aping any furriners.

Retriever said...

Good post and comments. Amongst other things, I am afraid of more protocols that define how doctors, etc can treat their patients, what meds, etc. "Best practices" are useful concepts, but not if mandatory.

I could maunder on for an age, but here is simply one of my pet issues (one that will become even more of a one should we move to a system of national health insurance, government run): how even those of us with generous private health insurance are increasingly being forced to accept generic instead of name brand drugs or no coverage of the cost of the prescription at all.

Some of the kid's meds are still only available branded (give me an A, give me a B, give me an I...) and get paid for. But others, available as generics, don't always work as well. Many generics are NOT in fact equally effective (or even the same strength) let alone tolerated.

Any psychiatrist (or family member of a patient) knows that it is hard enough finding a med that works for a patient, and that they can bear the side effects enough to stick with it. To screw around with changing something that works, or not be able to try something else when the "standard" treatments don't work is truly insane.

Increasingly, the generics and some of the branded ones are made in China under less than tightly monitored conditions. In other words, similar things have and may in future happen as w dog food, infant formula from a certain source: different ingredients are substituted. The medicines are NOT equivalent, because they contain different ingredients in different percentages. Street drug dealers have known about this for generations, why should corporate crooks be any different in a country that only episodically showtrials a handful of those who get caught?

The NYT had some good pieces I linked to a while back on the bad news that more and more of even our branded drugs are now made in CHina (usually the active ingredients, then shipped to Canada, where they don't have to be tested for purity or monitored at all because they are not intended for the Canadian consumer, but are rather formed into pills and then exported to the Americans who think "Ah, made in Canada...handsome lumberjacks and honest farmers and Moosehead beer, good stuff..." The brand pharma stuff too, as the increased profits are irresistible. The thing is not simply the lack of ethics involved, but the subcontracting to thousands of small, often dirty or ill-supervised facilities there.


Chicken Little on This Issue

Anonymous said...

Hmmm....being a 'furriner' I'm going to opt out of commenting on this one because from past experience...

I'll just be Swiss-neutral and say that I think America should outsource their health care system to India - think of the fantastic job they do with telemarketing, and all for a fraction of the cost! -- health care can't be much more complicated... America doesn't need any more local job placements, surely. I'm right, aren't I?