An Open Letter to my Senators and Representatives.
August 10, 2009
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Dear Senators and Representatives:
RE: Heath care reform and Cap & Trade.
The goal of improved health care with a lower cost is laudable, but the proposed universal health care plan is unlikely to achieve either of these goals. Although the health system is very complex, it still may be possible to fix, without risking the good care, which most Americans feel they have. The problem with the current proposal is that it hurts the young, the old, the people with good health insurance, the individual taxpayers and many small businesses. I’m not sure who will benefit, but I feel confident that most will be harmed by this proposal.
Access to health care is important, but not more important than food or housing, so health care should not be elevated to a right unless food and housing are also elevated to this status. Unfortunately, the President appears motivated to follow his campaign rhetoric, even though he clearly does not understand health care enough to make an informed decision about the indications for a pacemaker or pain medications. This lack of knowledge can be dangerous and makes people nervous, especially when ill defined health care reforms are rushed through the Congress.
His one successful legislative effort was the tobacco tax to help fund child care. I give him credit for this, because it did take some political courage to create a regressive tax on lower income Americans, which may help reduce tobacco use and its associated diseases. The President should consider small win-win type proposals to gradually correct the problems with health care. This would demonstrate maturity and patience, which many Americans believed he had prior to his election.
Instead of just complaining about the administration’s proposal, I felt that I should at least offer some suggestions, since I am a physician and have practiced medicine and cardiology since 1987.
First, make the diagnosis or define the problems:
1. High cost of health care.
2. Lack of access to health care for some.
3. Misunderstanding of problems 1 and 2.
The high cost of health care is due to multiple factors including: Provider salaries, hospital fees, insurance profits, malpractice costs, billing fraud, medical advances, aging population and overutilization by underinsured individuals with various degrees of psychiatric problems (people with anxiety, depression, and personality disorders who have multiple somatic complaints but few actual problems). I suspect that the biggest cost comes from hospitalizations and emergency room evaluations, which includes many of the cost factors, which I noted above.
Lack of access to health care as measured by the uninsured is not valid since many young, healthy people with good incomes don’t get health insurance because they view it is a waste of money, which may be true for a majority in this group. The other main falsehood is that if you do not have insurance, you do not get treated. I have never seen anyone turned away from emergency care for lack of insurance, citizenship or any other reason. Elective care can be delayed by lack of insurance, but even in the administration’s proposed system, delays in elective care will be inevitable.
Now for some simple remedies, none of which are new and many of which are not popular with the political left, but as a Senator I assume that you represent all of the people of the United States and not just your political base. If I am wrong, and you only listen to certain types of people, then let me inform you that I am a Hispanic physician, who grew up middle class in Southern California. My father was a union worker at US Steel for most of his life and my mother worked in a textile mill, until she got a job as a clerk at the Harbor General Hospital pharmacy. I voted for Jerry Brown for Governor and went to Linda Ronstadt’s Hispanic music concert at UCLA. I subscribed to public television and have a large fruit and vegetable garden in my backyard. My carbon footprint is 1 billionth that of Al Gore (my estimate) and I don’t own a gun or belong to the NRA. And now for my proposals:
1. Don’t make any major changes to the system, which you can’t repair.
2. Don’t concern yourself with the small items of health care like physician visits, medication costs or preventive screening. Concentrate on the big expenses by encouraging people to carry only Major Medical Insurance, which covers major surgeries, major hospitalizations and cancer treatments. These plans should also have a high deductible to keep the cost of the plans relatively low. Even young people would likely get these plans, since they would cost very little for this group, except for maturity care, which would be extra.
3. Encourage fee for service primary care. Please view the Fox Business video interview of Dr. Garrison Bliss from Seattle. By being paid directly from his patients, he is able to keep the cost of his practice down, while providing good care. You can safely assume that he has been providing good care, because if he had not, he would have lost his patients to the competitive Seattle medical community long ago. This model offers many positives financial benefits including: Better reimbursement for primary care providers, less administrative hassle for primary care providers, and less cost for providing care due to less money going for insurance profits. As noted above, good patient satisfaction can be achieved with this plan. Mental Health professionals may also use this primary care model.
4. Tort reform beyond just a cap on pain and suffering. Defensive medicine is a high volume problem seen in the emergency departments every day. Just about every headache, abdominal pain or atypical chest pain will trigger expensive (rule out) tests such as CT scans or short stay admission. Many of these problems could be evaluated in a less expensive way in the office, if the liability risk could be controlled. So yes, we need a cap on pain and suffering, but more importantly we need a Canadian style control of lawsuits. In addition, we need to limit the liability associated with discharging patients from the emergency department who have vague, somatic complaints or minor problems.
5. Expand the financial benefits for health saving accounts by allowing a larger amount of income to be tax free if placed in an account, which could only be used only for medical care and food.
6. Government subsidy for low income Americans, which would allow them to purchase a Major Medical insurance plan with a lower deductible, subsidized by the government.
7. Reward good behavior and taxing bad. Example being the tobacco tax and the tax on alcohol.
8. For people who still choose not to carry any insurance, their medical bills will be based on the current Medicare rates. Bills not paid in 120 days are passed to the Federal government to collect via the income tax and the medical provider gets to write this amount off on the Federal tax.
This solution does not require a government appointee to become the nations health care arbiter. This person would likely make many unpleasant rulings, which are based on political beliefs and not medical knowledge. People wrongly assume that evidence based medicine can dictate appropriate care for most medical problems. Heart failure, which is the most common hospital diagnosis, has been well studied, yet only 10% of the treatment recommendations from the Heart Failure Society of America are based on good clinical trials, most of the recommendations are expert opinion. So personalized expert opinion from your own physician or a political decision from an appointed bureaucrat, the choice is ours. Can you appreciate the concern of many Americans, that the administration’s health care proposal will lead us to the system that is present in the UK?
I want to also briefly discuss the Cap & Trade bill, which has passed the House. The Senate must now decide if the potential benefits to Goldman Sachs Group, Inc. (GS) and other special interests are worth the potential harm to multiple other businesses, employees, and the federal tax revenue. In spite of the recent stock market gains, the health of the economy is still not good or even stable. You don’t take an unstable patient for an elective exploratory surgery with only the hope that you might make them feel better 15 years later. Maturity, thoughtfulness and common sense are virtues, which began our country. Hopefully, they have not been lost.
Consider, that your votes on these bills will not only change our lives but yours. Very simply, our health lies in your hands. Please remember these two ideas:
1. First do no harm.
2. Serenity prayer.
Footnotes to be included in the comment section.
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