Crisis in health care

by David Smith

A few weeks back I had an up-close and personal encounter with America’s dysfunctional healthcare system. I’ve written about it before in these pages, but there’s nothing like personal experience to make it all depressingly real.

It started innocently enough, a stomachache a couple of hours after eating with a colleague at a Thai restaurant. I considered the usual possibilities: some bad chicken curry, acid reflux, gas; or perhaps the beginnings of an ulcer. But then the muscles in my mid-back began to cramp as if in response to the burning, acidic pain in my stomach — this was something brand new. I gobbled antacids, gas pills, Prilosec and everything else we could find the medicine cabinet, but nothing dented the pain and explosive pressure in my abdomen and soon my wife and I were speeding along the Long Island Expressway toward the emergency room.

If you’ve ever watched ER, you’re probably picturing young doctors in scrubs running out to meet the car, but that didn’t happen. Unfortunately, this was my first dose of reality. My wife yelled for a wheelchair, but security casually told her she would have to go inside and find one herself, but first, she’d have to park the car. That meant I would have to enter the ER by myself. Surely, doctors and nurses would rush to my aid as soon as I stepped inside, wouldn’t they? Not a chance. I stumbled into the ER hyperventilating and bent over from the waist in pain, and not only did no one come to my aid, but no one even looked up at this middle-aged white man in anguish except some of the many other people waiting for attention, most of them immigrants and minorities. I might as well have been invisible.

Now, we’re not talking about an inner city hospital here, but a modern, well-endowed teaching hospital in a very expensive region outside New York City– the kind of area where BMW, Mercedes, and Audi dealerships are jammed together check by jowl along with high-end stores and restaurants. On the bright side, the waiting room was beautifully appointed with polished marble floors, and fruitwood paneling — the best that big endowments can buy. The room had been divided into a series of smaller waiting rooms each with a flat screen television and comfortable couches. However, there was only one nurse plus a couple of clerks on duty, and nobody was in a hurry to deal with the crush of patient traffic. As I had learned from previous visits to area hospitals (we take care of very elderly parents), unless you are visibly bleeding, gunshot, or having a heart attack, you must wait your turn to be seen along with the rest of the walk-in traffic, most of whom are using the emergency room as their primary care facility. That means, you can be seriously ill, yet compete for attention with someone with a head cold, or a rash. So, on a bad day — and most days are bad days — it can take between five and ten hours just to be seen! And that was my predicament. Fortunately, my wife, a hospital worker, rescued me, mentioning the open sesame or magic words of the ER: CHEST PAIN, and suddenly I went to the head of the class. It was only a little white lie; the symptoms I had could easily have been cardiac in nature.

Shortly thereafter I was wheeled into the inner sanctum of the ER, the treatment area, a rabbit warren of examination rooms. Typical of today’s emergency rooms, it looked like a war zone: the halls were lined with the beds of patients and their relatives waiting for rooms in the hospital. I was to spend the next eighteen hours there, undergoing every basic test known to man, including an x-ray series, a couple of sonigrams, a CT scan, a HIDA scan which involved, respectively, swallowing a couple of quarts of dye and being injected with radioactive material. Fortunately, I was full of morphine and other painkillers during this ordeal. Around three in the morning, it was determined that I had a “hot” gallbladder that had to come out ASAP. But more about that later.

America’s Health Care Crisis

What I had just encountered in the ER is not a new phenomenon; it’s been building in the inner cities and urban hospitals for decades. As we’ve been constantly reminded by the presidential candidates during this primary season, approximately 47 million people in this country do not have health insurance and even more are dangerously underinsured, which means they cannot afford regular care and the often expensive tests that come with office visits. So, many people bundle up their sick children and grannies and trundle off to the emergency room for every fever, cold, and twisted ankle, knowing that at least there, they cannot, by law, be turned away for lack of insurance or inability to pay.

Despite President Bush’s cavalier declaration that no one lacks health care in America because they can go to the emergency room, the ER as a primary care facility is a terrible, terrible solution. It means much needed triage facilities are clogged up with run of the mill non-emergency cases, and the extravagantly marked-up costs for these visits will be passed along to the rest of the country through much higher costs and higher insurance premiums. Truly, when it comes to medical costs and insurance companies, there is no free lunch.

• According to the New England Journal of Medicine, 31% of every healthcare dollar spent in the United States goes to administrative costs, and our doctors and nurses now spend between one-third and one-half of their time handling paperwork.

• Half of the profits in the drug industry worldwide are paid for by American citizens

• Premiums for businesses are up 500% since 2000. It’s become such a huge issue for GM that the Economist called the automaker “a pension hedge fund and health insurance business that happens to make cars.”

• Our economy is losing $130 billion a year because of the untreated illnesses of uninsured Americans (The Institute of Medicine estimate) • Americans priced out of the market are becoming “medical tourists” — traveling to Europe, Mexico and Central America for dental work, joint replacement, and elective procedures such as cosmetic surgery.

• We suffer 18,000 unnecessary deaths annually due to lack of health insurance — more than four times the number of combat deaths in the last five years in Iraq

There have been a shelf-load of books written about our health care crisis during the last few years (I ought to know; I’ve read many of them), and I would recommend many of them to you, despite the fact that many of them marshal the same dispiriting facts about the true state of medicine in America. Most of them arrive at similar conclusions: that we need a single payer system of universal health insurance, which either eliminates or marginalizes the role of private insurance companies. Crunch the numbers, they say, and this change alone would pay to insure the vast army of the uninsured.

Critical: A New Look at the Problem

Now, however, there is a new book on my shelf that looks at the problem from the perspective of a legislator and veteran of the Washington wars. Former Senator Tom Daschle of South Dakota, who was Senate Majority Leader during the latter part of his tenure in Congress, has written a slim volume titled Critical: What We Can Do About the Health-Care Crisis. If you want a serious overview of the problem, including a legislative history of attempts to address it going back to the New Deal, you’d be hard pressed to find anything better and more readable than Senator Daschle’s book.

Not surprisingly, we learn that the American people have been clamoring for some sort of national health care for a long time, but that well-funded interest groups have denied them over-and-over again through misinformation campaigns such as the infamous Harry and Louise ads during the Clinton era which painted the picture of some sort of Stalinist era bogeyman managing our health-care decisions, never mind the fact that Americans were already very happy with an efficient government administered healthcare plan called Medicare.

It’s a sorry history, and there is plenty of blame to go around, including the American Medical Association, the hospitals, the pharmaceutical industry, and the insurance companies. Daschle describes “powerful supply side forces” in American healthcare, which are unique among industrialized countries, that both “create and satisfy” demand for medical services. Consider the sudden scourge of erectile dysfunction, and restless leg syndrome — diseases that didn’t really exist until drugs were developed to treat the symptoms.

Daschuel quotes David Mechanic, a health care policy expert at Rutgers University to define the scope of the problem: “…more and more of what were once seen as social, behavioral, or normative aspects of everyday life, or as normal processes of aging, are now framed in a medical context…Whether wrinkles, busts, or buttocks, impotence or social anxieties, or inattention in school, they have all become grist for the medical mill.”

Daschle points a finger at Congress and the Executive Branch too. Not surprisingly, in the end, our problems have less to do with medicine than about partisan politics and money. Toward the end of the book, Senator Daschle supplies us with some sobering facts: “In terms of political clout, the health care industry is second to none. Between 1996 and 2006, pharmaceutical companies and other manufacturers of health-care products spent over a billion dollars on lobbying, more than anybody else, and twice as much as the oil and gas industries. Insurance companies, including health insurers, ranked second.”

Now, once again we have an opportunity to change things for the better. The opportunity usually comes around when there’s a big political shift in the country, such as the long-awaited end to the Bush era. Whoever wins the contest this coming November, will enjoy a honeymoon period during which many things will be possible that were not before, especially if the election sees a significant power shift in Congress. Daschle, who witnessed the last such opportunity, the first election of President Bill Clinton, and the almost giddy anticipation of a new national health program, with bi-partisan support. The Clintons squandered the opportunity, in part, by trying to be too specific about all the changes at the outset, and launching a huge number of committees to handle the job.

In retrospect, it should have been predicated that the whole enterprise would collapse under the weight of the inevitable disagreements about the shape of the new enterprise. The Clintons also waited too long to bring their legislation forward, until after Bill’s approval rating had plummeted due to the mess in Somalia among other crises. Federal Health Board Through an examination of the Clintons’ failure to legislate universal coverage, Senator Daschle leads into the major theme of his book: that we should not, and cannot leave the formation of the infrastructure, nor the rules and regulations of the new program to the politicians.

“There is a strong argument to be made,” says Daschle, “that appointed experts, ‘proceeding in a deliberate sometimes plodding way,’ would make better health-care decisions than politicians.” Daschle’s idea is to create a “Federal Health Board” based on the Federal Reserve Board to make major health care decisions for the United States. Regardless of whether our new national health care system is a single-payer system or an combination public/private system (more likely) Daschle’s Federal Health Board would set medical policies in the same way the Federal Reserve Board sets monetary policy. The members of the board would be political appointees, but would be subject to confirmation by Congress. Such a board would “have the knowledge to make complicated medical decisions, and the independence to resist political pressures,” according to Daschle. There are successful examples of such a central health authority in various European countries such as Great Britain, Germany, and Switzerland. Typically, the responsibility of such boards is to set standards for patient care, and for cost effective procedures and drug therapies for common illnesses. In other words, they are responsible for keeping costs under control while ensuring the highest possible care.

The upside to a Federal Health Board is that it would take both the politicians and the lobbyists for the medical and insurance industries out of the picture allowing us to finally provide health care for all our citizens. Historically, the right wing (compassionate conservatives) has blamed the rising costs of health care on average citizens who use the system too much and too often. The assumption being, I guess, that you shouldn’t go the doctor unless a major limb has been sheared off in an accident, or you’ve come down with hanta virus from cleaning the rodent dropping from your garage. Otherwise, you should just “man-up” and stop complaining.

Surprisingly, Daschle agrees with them to some degree. Unlike our European counterparts, Americans are believers in new treatments and new technologies, and think that we should always have the benefit of the latest and greatest advances in medicine, and our doctors, who are terrified of malpractice suits (can anyone say “tort reform”?) are all too willing to send us off to get unnecessary CT scans, just in case.

Tale of the Hot Gallbladder

This is probably why I ran up a $31,000 bill in just a couple of days in the hospital, all without spending a single night in my room. As I mentioned earlier, the young docs assigned to my case, sent me out for all kinds of x-rays, and high-tech scans just in case I had pancreatitis, heart disease, a hiatal hernia, or who knows what else. These tests ran up the bill exponentially.

Fortunately for me, they finally decided I had a crummy gallbladder that needed to come up immediately. And here’s where the miracle of modern medicine comes in — the fabulous laparoscopic cholecystectomy, whereby the surgical team makes several tiny incisions in your abdomen, inflates it with air, inserts a tiny fiber optic monitor through the navel so they can see what they are doing, and then takes out the gall bladder through the other small incision. For those of you old enough to remember LBJ showing his foot-long gallbladder incision scar to the press in the 1960s, the so-called lap choli is an enormous improvement. All I have a three little bumps on my belly. Why, if I had the body for it, I could even wear a thong on the beach this summer without fear of showing an unsightly scar.

Despite the improvements in the surgery itself, however, I spent an uncomfortable night in post surgical recovery where I struggled against the debilitating effects of general anesthesia and the residual morphine in my system. When I was finally sent to my room, I was in for a big surprise. The room was amazing. Just like the ER, the entire floor was fruitwood paneling, carpeted floors, and flat screen televisions. When staff came into the room to check my vitals or stock the bathroom with fresh towels, they actually apologized for disturbing me! And you couldn’t hear a sound from inside the room! No ringing bells, PA system announcements or loud voices, just blessed quiet, which was nice because I was still very uncomfortable. But I felt like I could actually recover in this environment! There had to be some kind of mistake. As it turned out, there was no mistake; I had been assigned a private room in the ultra fancy VIP floor reserved for the likes of Jennifer Lopez, multi-billionaires and foreign dignitaries because I was married to a hospital worker (who is not a multi-billionaire). There had to be a catch. We’re talking about America’s dysfunctional health care system here.

And of course there was. Shortly after I had my post-surgical liquid diet lunch, a ten-year-old surgical resident came in to drive me from the Garden of Eden with a flaming scalpel. He asked me how whether I was comfortable and I tried to joke with him: “I make a living,” I said, and humorless drone that he was, he didn’t even crack a smile — that is, until he told me that he was discharging me. According to hospital guidelines, you should be able to go home within 24 hours, no matter how you feel. I was told later that the surgical team received bonuses based on how well they controlled “length of stay,” which is a nice way of saying getting people out of the hospital as soon as possible to improve profitability. Maybe. But I like to give them the benefit of the doubt; I'd like to think that the real reason they booted me out was that they needed the room for Jay Lo again.