Sunday, August 9, 2009

Another Hair-Pulling Letter to the Editor

Sometimes, when I see letters to the editor in our local paper, I wish I had more hair because it would make it more dramatic when I pulled it all out. Rest assured, the Richmond Times-Dispatch (RTD) and I would not be friends under most circumstances. We have different points of view on many things, and probably would not make good roommates.

However, now and then, they publish things that seem more egregious than normal. Such is the case today. To my knowledge, the RTD has not published anything like a fair discussion of healthcare reform. They continued that trend today with this post.

So, when I see things like this, I feel like I need to respond. I write letters back. Sometimes I send them, sometimes I don't. But, if I write them, I tend to post them here because it makes me feel better.


To the Editor;

I am writing in response to Dr. Stephen Long’s opinion piece titled “Mad Rush to Reform Seems Certain to Harm the Patient” that was published in the Commentary section of the August 9 2009 Richmond Times-Dispatch. Although I have not been in practice as long as Dr. Long has, I have chosen to practice in medically underserved communities throughout my medical career: from studying at the Virginia Commonwealth University School of Medicine (formerly MCV) to completing a residency in Blackstone Virginia to 4 years as a Family Physician in Keysville Virginia and now 2 years working on the south side of Richmond at the Hayes E. Willis Health Center. During this time, I have run into healthcare access issues on a nearly continuous basis, and I feel that I have a different perspective on healthcare reform than Dr. Long does.

Dr. Long states that legislators are over-inflating problems with the current healthcare system in order to scare voters and to pass significant healthcare reform. The truth is that (by Dr. Long’s numbers) nearly 17% of the country is either uninsured or underinsured. On a near daily basis I have to guide patients as to which $4 prescriptions are the most important and which can wait, as patients cannot afford all of them at once.

Dr. Long speaks about the concern that a public health insurance plan will “adversely impact the current excellent and immediately accessible care available to all Americans.” I think this statement is incorrect. Uninsured patients (1/6 of the nation) lack excellent and immediate accessible care. In fact, in many cases, they lack care of any kind unless they work with a free clinic or community health center, or end up in the Emergency Department. A number of those who have insurance have high-deductible plans—the only way they could afford to buy the plans—and try to defer care if possible to reduce costs. In my opinion, making the options to access care available to everyone is the better choice, even if the cost might be a delay in accessing elective care. When my patients cannot be seen in a Cardiology clinic for 6 months, then we cannot claim we have “immediately accessible care”.

Dr. Long repeats an oft-told story about how a public health insurance plan would “simply dole out government-controlled health care.” This claim is made over and over and over and over again. I have two issues with it: 1) health care is already doled out—rationed, if you will—by for-profit insurance companies that are trying to make money for their stockholders and 2) there is nothing in the current proposed legislation that would direct such an action. There is a provision for comparative effectiveness research, true, but that would simply provide information for physicians to make better decisions with their patients.

A brief word about the medical research Dr. Long fears might dry up: a great deal of biomedical research takes place with government funding at universities and at the NIH. For-profit pharmaceutical and medical equipment companies tend not to invest at these early stages but rather buy the technology later on and then sell it back to the citizens that played a role in developing it. But that is a whole other argument. Suffice it to say that I do not believe medical research and development would suffer.

Regarding the government’s supposed failure to sustain Medicare: Medicare is failing for any number of reasons, from the fact that it insures an increasingly older and more ill group of patients to the fact that reimbursement for high-cost interventions and specialty care outstrips the reimbursement for solid preventive health care. Medicare is, in fact, much more efficient in its use of funding and resources than private plans are, and patients who participate in Medicare are overall very happy with the program. Medicare’s funding problems are not the result of a failure of the program, but rather to the run-away costs associated with healthcare and the fact that high-cost patients are more likely to be enrolled in Medicare.

I also challenge Dr. Long, and other members of the Coalition to Protect Patients’ Rights, to explain to me how a system based on tax credits, health savings accounts (HSAs), co-ops and vouchers is supposed to work? Tax credits and HSAs stand very little chance of helping my patients who work minimum wage jobs without benefits and who are working paycheck to paycheck to meet other obligations. Vouchers might help with this, but it would depend on how much the vouchers cover and how much the available plans cover. The Commonwealth Fund issued a study showing that, in the private insurance market, 75% of patients who sought to purchase insurance during the study period ended up not buying a plan: they could not find an affordable plan or did not qualify for available plans. So why prop up a system that does not work?

The truth is that America needs meaningful healthcare reform—reform that will provide true access to needed medical care to all Americans. This has not been accomplished through the private market; otherwise we would not be in our current situation. Private, for-profit plans are not the answer. Recently, a former high-ranking executive at Cigna has spoken out about tricks that private health insurance companies use to deny care. A public health insurance plan, such as that being discussed as part of healthcare reform, stands as a strong alternative. This plan would provide a way to control costs in the marketplace while making insurance available to all Americans. The plan could act to keep prices down by negotiating with pharmaceutical and medical technology companies on behalf of the plan members. The plan would also be competing in a public marketplace—if the public plan was not the more efficient, more cost-effective option, than the private plans would outlast it. A public plan would also be answerable to the public—the voters—not to a boardroom and private investors. This plan would stand to reduce costs for all Americans and reduce the costs to businesses, which find themselves ever more burdened by the costs of providing health care insurance.

Health care insurance, as it is, is a terribly flawed system. The New England Journal of Medicine recently published an article showing that if your household income is high, then the status quo is sustainable for a long time. However, if you are low-income, you are already feeling the pressure of these unsustainable costs and will be under greater pressures in the near future. I have chosen to work in communities where low-income households predominate, and I have felt the urgency and pressure they face. I have had patients ask if they could hold off on studies or treatments at least until Medicare kicked in. In a country where over 50% of bankruptcies involve costs of medical care—and most of those families had medical insurance when they first got sick—there is no time to waste. This is an urgent situation. While discussion and debate is important, it must not delay the implementation of real healthcare reform. I also urge concerned citizens to speak to their elective representatives: we need to support the White House’s efforts to enact legislation making access to our healthcare truly free and open to all.


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