Natural Cure

Random thoughts that I’ve got to get out from the developing country that is Guatemala. And for me to rationalize wasting time on the internets, it’s in Spanish (and then English).

Primero punto: la polucion. Respiro muchas fumas de carros y autobuses todos los dias, y la polucion no ayuda mi asthma. Estoy tosiendo con un tos seco. Ugh.

Dos: necesito una escopeta. Todos la tienen aqui… en las escuelas, las farmacias, el centro commercial… increyible. Es mas por la espectculo que uso, pero es un poco difficile a comprender.

Tuve un obsecion con mis intestinos por esta semana. Es completamente mejor ahora, pero al comienzo de la semana, un sonido pequeno de mi estomago me preocupe mucho. Tuve mucho miedo de problemas gastronomicas, pero ahora soy fatalista.

1st issue: the pollution. I’m constantly breathing fumes from cars, buses… it’s awful. My cough-variant asthma is in full effect.

2: I need a shotgun. Everyone here seems to have them. At schools, pharmacies, the mall… it’s incredible. It seems like it’s more for show, to scare people off than for actual use, but I still don’t really get it.

I have had a ridiculous obsession with my bowels this week, but now it’s better. I swear, the tiniest gurgle from my stomach would send me into a panic. I’ll still eat safe (no street food), but otherwise I’m giving up. I hope I don’t get anything, but it’s probably out of my control.

Voy a esperar de subir archivos algos photos si yo puedo.

I’ll try to upload some photos if I can.

(Feel free to correct mi espanol si quieres… escribo a computadora muy rapido!)

After a day of mal estomago, Im feeling better, partially thanks to the fact that I found out I just passed Step 2 CS, my last requirement in order to graduate.

Back to inhaling bus fumes. It sounds like a lot of people wouldnt mind some updates while Im down here, so Ill see what I can do–but start practicing your Spanish, ustedes van a necesitarlo!

I hope you’ve enjoyed the series and it’s made you think a bit about health care, health policy, and how difficult it is to come up with solutions to our health care problems. I appreciate the civil discussion and debate, and continue to welcome any other feedback!

A few topics I wanted to cover but didn’t have time to:

• Science education - If we want our patients to understand medicine and the science behind it, they need to understand (and accept) the basic tenets of science — randomized studies, for example — and perhaps that’s where we’re failing. People seem to have a miraculous ability to accept the science they have chosen to believe (antibiotics for bacterial infections, germ theory) while ignoring rigorous science that doesn’t fit with their world view (thiomersal is not responsible for autism).
• Patient Autonomy - Has it gone too far? By asking patients or their decision-makers to decide, “Do you want to keep trying failing treatments or terminate care,” perhaps we’re putting too much decision-making in the hands of a person who clearly doesn’t want to feel responsible for “pulling the plug” on their mother (who would?)? While no one wants to die or wants a loved one to die, is it fair to other people who have a better chance of hope of recovery to take up a hospital bed to treat a demented 95 year-old man who won’t get any better?
• And many more!

On that note, it’s been a pleasure writing about my journey through medical school, and I appreciate everyone who’s joined me and supported me along the way.

I’m heading to Xela, Guatemala (aka Quetzaltenango) tonight for two months with Asociacin Pop-Wuj to do some intensive Spanish and medical Spanish training (as well as seeing their cigar-smoking saint, Maximn, and hiking and exploring) before heading back to be in a friend’s wedding. I likely won’t be blogging much, but hey, who knows. Since I now have an official job as a doctor (scary), I’ll be wrapping Over My Med Body up in time for Graduation in June. Stay safe and healthy and I’ll see you on the flip side!

yours,
graham

Me on Match Day, blogging away:

Throughout this series, I’ve documented just some of the big, elephantS in the health care room that truly concern me as a physician, patient, son, brother, citizen, and person. I’ve suggested abstract and theoretical policy ideas for how they might improve things, while providing very little practical information on how they might be implemented (tax hikes, law changes, policy changes). Because I’m skeptical that any of them would ever happen in today’s health care environment.

We need a single-payer for all the reasons I’ve stated in the previous post. But we need a single-payer even more to provide some sort of direction in this damn train wreck of a health care non-system in America. Pick almost any issue I’ve mentioned–or haven’t–that concerns you, and ask yourself if you think it’ll go anywhere without some sort of organized plan or director at the helm.

As I said at the beginning, the goal of a country’s health care system–and note, we talk about a country’s health care system, because the whole country’s population is affected by it–should be to make its citizens the healthiest they can be. Right now we have a system that maximizes profit; this coinflip sometimes comes out with also optimal healthiness, but often it couldn’t care less if it makes its patients healthy. Case in point: the Hepatitis C outbreak in Nevada at a colonoscopy center, where 40,000 people may have been exposed to hepatitis and HIV because staff were re-using syringes to save money. Or the woman who finally sued and beat the pants off Blue Shield of California because they dropped her coverage when she started chemo for her breast cancer. (Sick people cost money!)

We currently have a system where each health care player is trying to pull the system in a different direction, and it really leads us to gettiing nowhere, fast. The private health insurance companies certainly have no interest in bigger national goals, since they for the most part don’t have huge national markets. 30% of people change health insurance each year (no surprise when people change employers so often these days). So it’s no wonder that the HMOs aren’t interested in having comprehensive preventative care or an electronic medical record: long-term benefits of long-term programs aren’t ever seen by these companies–their patients have gone to another HMO!

There are a ton of perverse incentives in our current health care system, and at least in health care, it’s worse for all of us. Hopsitals currently advertise that they have the best heart centers, the fastest ERs, etc.–hoping that they can make more money and often just keep themselves open (rightly so: what good is a closed hospital to its community)? So hospitals have invested heavily in profit-making centers–heart centers, new scanners, etc–while providing fewer resources to other more broadly-useful services like primary care. But since there’s no one at the helm analyzing the data saying, “Wow, this community could really use a new rehab unit, since it has a very high number of returning Iraq war vets,” no hospital has any reason to build a rehab unit–unless they can make it profitable. Again, money/profit is a top priority, not health care needs.

And when hospitals aren’t able to compete, they close. And hospitals over the past 30 years have typically closed in the poorest neighborhoods (which often have the sickest patients). So then these patients are now without a hospital and without a doctor. Which eventually makes it worse for all of us.

People Want Reform.
Look, take a gander at any recent poll on health care, and you’ll see that people recognize that this system is in trouble. Whether it uses the words “single-payer” or “national health care system” or “significant change,” significant change is going to happen. It’s just what kind of change. And as I’ve said before, if we don’t take an active role as the nation’s health care providers saying what we think is best for Americans’ health, some system worse than what we can even imagine will fall into place.

It’s not just the uninsured that are voting in these polls–it’s the insured, too. And I believe for people with insurance to put their faith in a new system, it has to offer them something better than what they’ve currently got. And that’s why I’ve made the case for single-payer: it would provide some level of leadership and direction for our health care system, and, because of that, I believe would drastically improve our health care system.

Why Would It Be Better

• Better health service, policy, and epidemiological research. We could use some nationalized system to collect anonymous data to see how people do with condition X or treatment Y. Currently a lot of this data is confined to the Medicare or VA populations, which are often not good representations of the entire populations.
• Doctors would have more time with patients. Currently so much time is spent with paperwork that doctors spend less time with patients, and have less time to keep up current data and research in the journals.
• All the reasons stated above, including people never going without health insurance. I find it interesting that we can be frustrated with Medicare’s “never events” at an institutional level, but don’t apply that same perspective to individual patients. In a perfect world, should no one at a hospital fall and break their hip? Sure, but it’ll happen, no matter how hard we try to stop it. Similarly, should people never get sick when they’re uninsured? Sure, but it’s going to happen, and should they be forever punished for it? I don’t think so.

Single-Payer Won’t Solve Everything
Throughout this series, I’ve presented a number of concerns for this health care system, without really mentioning “single-payer” as a solution, because it alone is not. Health care financing alone will not solve all the problems of health care in this country, but it will be a big step in the right direction. With a single-payer system there would motivation to fix the health care system, as we would have a publicly-financed system whose goal is to optimize our health care system in every way possible.

I don’t buy the argument that “all government is bad.” There are certainly good laws out there, and certainly bad ones. The No-Call List law has been amazingly successul; the NIH is a government organization that divides up billions of dollars a year for medical research; fire and police departments keep us safe, and libraries provide their communities with access to books and information. I certainly don’t believe that any of these would be greatly improved by privatizing them and adding a profit component.

Would single-payer (or any big health care reform change) cause massive changes in our health care system? Absolutely, but I believe to solve or improve many of our health care problems we need massive change. Massive change happened when we gave women the right to vote, or decided that segregation wasn’t acceptable, but I’d argue we all now view these things as fundamentally improving society.

Many of you I’m sure will not be convinced by my arguments. That’s fine. But if that’s the case, it’s your job to come up with a better answer that also has the ability to address the other issues this country is facing besides just paying for health care.

(For example: ED docs love to bitch about EMTALA and people taking ambulances because gas is expensive, but I have yet to see other reasonable ideas for solutions from them.)

You knew it was coming, my single-payer post. It’s a nice wrap-up to the series. (I figured since I was agreeing with KevinMD and Panda so much I had to do something.)

I could make my argument for single-payer in any number of ways, but you’ve probably already heard them:

• Human dignity. Everyone should have health care as a human right. That people deserve health care, and as a wise family practice doc from Idaho wrote, the uninsured pay for their health care with their dignity. That almost all of the uninsured and underinsured are hardworking, tax-paying people who either make “too much” money to qualify for programs for the poor like Medicaid or don’t make enough for their employers to also provide health insurance. Or that health insurance is often way too expensive for their families, or even if they bought health insurance, it wouldn’t cover their major problems, like their kid’s asthma (sorry, pre-existing condition).
• We the taxpayers and insured are already paying for the uninsured in the form of higher taxes, higher insurance premiums, and longer waits for our own health care (remember, we’re all connected). Since we’re humane enough to have EMTALA and not let people die on the streets, people are going to get some level of care, no matter how poorly planned, poorly organized, or terribly chaotic it is. We might as well just pay for everyone and get a better bang for our buck, no? Isn’t that the American way, to at least get a good deal?
• Economic growth is seriously stunted by our current non-system. Why did the Jelly Belly factory cross the border? To get cheaper health care costs in Canada. (True story.) In our global economy, take a look at any American industry and you’ll see our health care costs stick out like a sore thumb–and this makes American companies have higher costs and are therefore less competetive. US automakers currently pay more for their employees’ health insurance than the steel to build their cars (which is why renowned health care economist Uwe Reinhardt refers to the American car companies as health insurance providers financed by selling cars).
  Many people–especially potential small business owners/entrepreneurs–simply forget any aspirations they have of starting their own business because of health care costs. If you quit your job and lose your health insurance and then get sick, you’re screwed. So there’s an incentive to stay in a job one hates, no matter how unproductive the worker is, because it provides them with health insurance.
• We already ration care. Many people cite a valid concern that single-payer would lead to ominous “health care rationing.” They do not realize that we already ration care: based on ability to pay, not health care need.
• Single-payer will save us money. Take a look at any proposed health care scheme, as many economists have in multiple previous studies (California Health Care Options Project, The Vermont Single-Payer Study, The Maryland Single-Payer Study, Massachusetts Health Care Studies, and Maine’s Single-Payer Microsimulation. Just to be clear, these analyses were done by The Lewin Group and Mathematica Consulting, two economic analyst groups. Not single-payer supporters), and you’ll see that single-payer is the only one that provides health insurance to everyone while actually costing overall less. It does this by doing bulk-purchasing of products, just like you do at Sam’s Club. It also majorly simplifies administrative overhead–think of the billions spent on duplicate forms a doctor has to process from the thousands of health plans out there–and the costs of increased health care usage are still absorbed in the savings. (I’m not about to deny that Medicare has paperwork requirements, but they’d be one set of paperwork requirements only.)

Like I said. Probably really nothing new if you’ve ever read any single-payer stuff on the Internets or my blog in particular. But I’m here to propose a different, and much more important reason we should adopt single-payer. We can’t afford not to.On To Single-Payer, Part 2