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Dr. Bruce Hector: Health care reform inching toward consensus

SCV Voices

Posted: August 22, 2009 7:40 p.m.
Updated: August 23, 2009 4:55 a.m.

A man upset with the proposed health reform bill stands to make a point during a town hall meeting held by U.S. Rep Peter DeFazio at the Douglas County Fairgrounds in Roseburg, Ore. on Wednesday.

 
As of mid-August 2009, the health care insurance reform debate has produced as much vocal public response as any recent social problem — and rightfully so, since it will affect us all sooner or later.

However, instead of thoughtful deliberation and careful consideration of the facts, mainstream TV and print media has focused more on fringe distortions such as claiming the bill will lead to a “federal death squad;” screaming matches between politicians and their constituents or between the electorate itself; and gun-toting, angry mobs.

This column is presented to outline areas of common ground on both sides, identify points of disagreement and shed some light on the basis for them.

Since several bills are in the different houses of Congress, the final version has yet to be written, but farthest along is the Democrat-sponsored HR 3200.

No specific Republican bill has been presented but common themes emerge which this author has extracted from Calif. 25th House District Rep. Howard P. “Buck” McKeon’s Web site.

First, all reasonable persons and both political parties agree we have a problem. The U.S. spends twice as much per capita on health care, ranks about 38th in international health statistics — worst of the industrialized nations — and still has about 47 million people uninsured.

Failure to address this issue will inevitably lead to mounting federal debt that can only be resolved with increased taxes, something neither party nor the public wants.

We must do something. Estimates are that 18,000 people die each year for lack of insurance, and to cover uncompensated care, those with insurance pay over $1,000 in each year’s premium. We all lose if some remain uninsured.

Both parties also agree that some insurance company practices are no longer acceptable. These include denying coverage for pre-existing conditions and rescinding coverage on sick individuals at the next year’s premium renewal.

This alone should help stem medical bankruptcy, which is 50 percent of all bankruptcies — and two-thirds of those folks had insurance when they became ill.

So, we all agree on one big issue. Neither side wishes to allow plans to interfere with a patient’s relationship with his doctor.

As a physician, I know this currently happens in the private industry with HMO or PPO plans, a point Republicans conveniently overlook while they rail against “government” getting between you and your doctor.

In contrast, Democrats say their plan will “let you keep your doctor if you like him” while overlooking the fact that for most of us, our employer chooses our health plan options and if our doctor is not part of his chosen plan, we lose our doctor.

Nonetheless, both sides seek a solution that will not infringe upon the doctor-patient relationship.

Both sides also emphasize preventive measures as part of all plans. These can include incentives to stay fit, not smoke and keep weight under control, increased access to useful medical information, encouraging more doctors to become family physicians, support for community health clinics, payment for immunizations and encouraging school-based service provision.

While the parties differ in several of the particulars, the concept of health promotion is supported by both.

Unfortunately, from a medical/scientific perspective, the true positive benefit and cost savings from such measures have not proven to be as great as first thought, though more research is needed.

Neither side seems anxious to dramatically alter the delivery system by creating new federal facilities, forcing doctors out of fee for service reimbursement or compelling our overabundance of specialists to become family practitioners, nor does either wish to shift to a single-payer plan, something that for doctors and hospitals could dramatically reduce administrative cost, thereby providing additional money for patient services.

Both also wish to increase payments for primary care services, reward high-quality care and integrate different health care sectors to avoid redundancy that leads to increased expense.

Democrats want to reduce payment for medical treatment failures that lead to hospital re-admission; Republicans have not addressed this issue.

Republicans want to increase home care to reduce institutionalization; I’m uncertain if HR 3200 addresses this since I have not read the full bill and it was not mentioned in the summary.

Both parties support changes that allow young adults to remain on their parents’ policies up to age 25.

The Democrats want to establish a scientific body to identify quality measures that work and those that do not; Republicans are labeling this idea a tool for government to control medical care, forgetting that already scientific research drives “best practices” models that have become the standard for all treatment guidelines, including those used by private carriers.

Both sides espouse a policy of no rationing of care. The Republicans allege this is what happens in other nations with nationalized delivery systems and would occur with a “government plan,” failing to recognize that if you have no insurance, care is already rationed.

And if you belong to an HMO or PPO, specialty services must be approved and are therefore subject to rationing.

The two main points of disagreement revolve around the “public option” and methods for financing the system revisions.

Democrats propose a public option as the only means to “keep the insurance carriers honest.”

Having practiced with the reforms of the late 1980s that lead to HMO and PPO plans as a tool to control cost, I have seen that insurance carriers did nothing to stem costs and must concur with this fear.

Republicans say this is the first step to “socialized medicine” and have seemingly drawn a line in the sand.

I remind the reader that not only was the same thing said when Medicare was proposed in 1965, but also at present almost 60 percent of health care bills are paid by state or federal entities and we do not call it socialized medicine.

President Obama has acknowledged in recent town hall meetings that government could compete unfairly if it repeatedly used tax funds to bolster the public option and has expressed a desire to “level the playing field.”

If we took the word of our last president about invading another country, perhaps we should hold the same level of confidence in our current chief executive. Maybe he won’t be able to do it, but if he says he will try, shouldn’t we trust him?

The Republicans seem to prefer to trust the private market. Since all major health care entities and pharmaceutical companies are publicly traded companies, we have no doubt about their allegiance to Wall Street. We have dramatic recent experience from the financial sector meltdown how much Wall Street cares about Main Street.

They used us till the house of cards collapsed, relied upon Main Street to bail them out, and now that they are starting to get back on their feet, reward themselves handsomely for their efforts.

Personally, these experiences cause me to trust Wall Street to only look after its “bottom line” and serve Main Street only to the degree that it benefits Wall Street’s profits.

Additionally, a look around the planet will note that the most successful and economical outcomes occur in nations with a strong national payer component, though not necessarily government-delivered service.

We should not seek to “reinvent the wheel” but learn from others who have taken this path before us — like Europe, which was in total collapse after World War II but has since rebuilt not only its economy but a health system much better than ours based on most objective standards.

On the other side is a fear of government intrusion into our lives. We tend to feel government is monolithic, bureaucratic and poorly responsive to the people’s needs.

We say, “Just look at the Post Office.” We hear claims of fraud and abuse of the federal Medicaid and Medicare systems. Many of these claims are probably true, but at the same time we must note that the greatest abuse of these systems has been perpetrated by private health insurance companies.

Additionally, we all trust government to look after our common welfare and safety through fire, police and Homeland Security entities.

We don’t rely on private agencies for these services.

Is not health care an equal issue of common welfare and safety?

Concerning financing, both parties are willing to extend some assistance to our poorest to obtain insurance, but the Republicans prefer to do it with tax breaks.

However, if you are too poor to pay taxes, a tax break is meaningless.

Republicans would also do so for small businesses to put them on more even ground with larger corporations. This seems fair and only the amount is in question.

They also propose allowing individuals to purchase insurance across state lines, another not-unreasonable proposition but one that would require common national standards for coverage, removing the issue from state jurisdiction which most Republicans usually prefer.

Republicans have also suggested we develop methods for lowering coverage cost to those aged 55-64 who are retired, pre-retired, semi-retired but have low to modest incomes.

Another option for this rather high-risk group is early inclusion into Medicare, but again Republicans fear that will be more “government” meddling.

To promote systemwide savings, Republicans bring out the tried and true tort reform (malpractice insurance) argument, not recognizing that this in actuality represents a small cost to the health care system and protects the people from medical mistakes that unfortunately are still too common.

They allege that “defensive” medicine drives up the cost, not acknowledging that such behavior is also good financially for doctors, which could be the more significant motivating factor.

The administration hopes to address this issue by better defining “best practices” and advocating coherence to that as a defensible standard, thereby reducing the vagaries exploited in malpractice cases.

A loud and repetitive fear is voiced as “How are we going to pay for it?” not realizing that our non-system is already paying for it in the form of payments to hospitals for uncompensated care from government and insurance, out-of-pocket costs that now represent almost 25 percent of annual spending, and excessive profits to health insurers and pharmaceutical industry not incurred by other nations.

If we already spend twice that of any other nation, we ought to be able to see where we overspend, identify a system that reduces it and avoid any significant overall increase.

Lastly, people fear this is being rushed through without ample debate. Most provisions of HR 3200 take several years to implement and the bill need only be completed by year’s end. Therefore, we have plenty of time for thoughtful analysis and discussion.

However, if we persist in name-calling, fact-distorting and fear-mongering, our time spent will be in building divisiveness rather than consensus about an issue important to all personally and the nation collectively.

It should be media’s role to foster this discussion rather than give air/print time to the rabble-rousers or quote the latest polls as if the issue is a sporting event with only one winner or loser.

This is our health insurance problem. We all need to win or we will all lose.

I urge The Signal and other media to focus on issues and not rancor, assisting the citizens they serve rather than provoking their anxiety.

As noted above, currently there are more issues upon which we agree than disagree.

Sound, sincere efforts by all citizens and legislators should lead easily to resolution of the others with the recognition that if the chosen path does not produce the desired results, we reserve the right to change in the future.

Dr. Hector is a resident of the Santa Clarita Valley. His column reflects his own views and not necessarily those of The Signal.

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