Stirring the Pot

Talking about healthcare is a big deal right now. I think it's a conversation that needs to happen. When Obama says, we need to do something about healthcare and their costs. Every day, people die needlessly because of inadequate care, because of poor preventive care because of lack or inadequate insurance.

We spend more than most industrialized nations per capita for healthcare yet we have a lower life expectancy and infant mortality. There are a lot of things I think might help (doesn't everyone) and I don't pretend I'm an expert. But I'm a potential patient and I know things will not get better unless I demand better. But I don't want to make doctors into assembly lines or to put them in a position where they can't make a living. In fact, pretty much none of my ideas are designed to do that.

But, my friend, the Mother told me that to talk about making a real difference in the cost of healthcare is going to address some of the big cost drains that skirt some ethical lines. She's right.

So, here's the question: is it always the right thing to fight for life no matter what? And, if not, where does one draw the line? You might be confused by the question - what does she mean? I'll explain. I'll also add that I'm not sure where to draw the line, whether there are two many variables to determine it legislatively or if that's something that needs to be determined by expert (i.e. medical - NOT insurance) opinion, but I do think the line exists. I personally think the answer to the first question is no.

Now, I said I'd explain what I mean. In some people's idea of a perfect world, everybody's have a monitor that would pop and say "Your liver is failing. Schedule liver transplant? Y/N" Then you'd stop by on your way home from work and get a new one and still make it in time for your three martini dinner engagement. But effective medicine isn't like that. Many times, a disease or a condition takes time and effort to overcome. It's painful and and requires sacrifice from the patient as well as time and care from the doctor. And sometimes, all that time and care and sacrifice will do nothing to change the end outcome except make the intervening time horrific.

So, here are some questions.

How much time and effort (and cost) should be considered necessary when there is no hope of doing more than prolonging the inevitable? Is it reasonable to spend, say, a million dollars to prolong someone's life for a year in the hospital on life support when that same million dollars might mean the difference between a productive life or an early grave for someone else. Or several someones?

What if that someone doesn't WANT that last painful and undignified year in the hospital?

How much should be spent providing care to someone who refuses to change their habits so that it has no chance of success. Does someone who drank his liver away deserve another one? Does someone who refuses to lose weight or rein in other habits has heart attack after heart attack? Should he get first dibs on a replacement because his is so much more damaged than another? This is actually a question that applies to me. I'm overweight and have several significant risk factors for type II diabetes. If I don't take steps now to address my weight and eating habits, should someone else be responsible for helping pay for my care?

Here's a hard one. What about children too malformed, too tiny, too underdeveloped to be truly viable. Children who are likely to be on full life support for months if not years if they live that long. Children with tubes and needles in them, children so delicate they can't be handled, who many never even know the comfort of a human touch. Or children born without brains or so severely damage they face years of surgery so they can limp through the remainder of their lives just severely handicapped.

It's not an easy question for me to ask as a mother, a situation that's heartbreaking. But is less hearbreaking to see your child only through a glass wall when there is no hope that the child will ever go home with you?

I don't know the answers to the questions and I suspect the answers depend on a variety of variables not here. But I'm not sure we're making these decisions today the right way. I know my father, who was a healthy man in his sixties when he was diagnosed with stage 4 colon cancer, would have preferred to just go home and spend his last days with his family. He fought at their insistence until his liver gave out and, though the doctors encouraged him to come back for more treatment, he went home. That was hard for me, but I respected his decision, understood his decision, admired the way he saw it.

Perhaps some people would choose to have herculean efforts in place to keep them alive until the last possible minute, no matter the pain, no matter the discomfort, no matter the financial burden on the system and on their families.

But many, I think, would happily trade those months or years of pain for a peaceful escape, would trade losing that family and their memories to Alzeimer's for a loving goodbye with the faces they know and love, would trade a few months in the hospital for years of working through debt for the people left behind.

So, once last question. In many states, people don't have the choice to decide to live or die when they face nothing but pain with an inevitable conclusion. Should they have it?

You know, it occurs to me I just don't stir up controversy as often as I should. I expect this will, hmm, stir something up.

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Can You Afford to Live?

In the US, one can't really talk about health care without talking about the cost of health care. You may be gasping. Politics! Say it isn't so, Stephanie!

Well, that's my point. Why exactly is health care a political issue? When did we say to ourselves, people are only entitled the amount of health care they can afford and even contemplating otherwise is a political hot-button topic? I'm completely floored, actually, with the notion that someone thinks that's anyone should go without health care if they can't afford it.

Who really thinks one's health is a matter of merit? That only those that deserve it become ill or injured? And why--why?--do we feel the need to protect the profits of insurance companies? If the government stepped in with their own program, it would provide an unfair competition with the insurance companies because the government doesn't have to make a profit. Um, so what? Much better that US industry is at a disadvantage because we're the only first world nation that still eschews universal health care? Much better to have families decimated and destitute because someone in the family develops cancer? Why do we think it better to protect the profits of those who make those profits on the suffering of others?

I wonder if anyone has done that math. Insurance companies make money two ways: first, failing to cover anyone they expect to pay out for and, secondly, charging the customers more than they pay out. So, replacing health insurance with a government single payer system doesn't have to be expensive - in fact, well designed, covering those who were already covered means it shouldn't cost the "taxpayers" a dime and those covered still pay less. Why? No profit; just break even.

It's covering those that aren't covered that brings up the cost. To an extent. Many of those not covered today are healthy. That's why they haven't bought insurance. Many of those not covered are not healthy; that's why they can't get coverage. So, does that mean, if you're sick and can't get coverage, that you deserve to die? That you aren't entitled to be cared for? What does it say about our society that this is even a question?

I suppose, for the sanctimonious, there's a belief that people get what they deserve. I am not one of them. I've seen children who died of a brain tumor and families who, more than dealing with the devastation of the loss of their child, had to also deal with a mountain of debt that can keep their other children from college, limit their options, ruin their lives. That's not justice. That's a tragedy, an insult added to unimaginable injury.

It doesn't have to be this way. In 2007, the U.S. spent $2.26 trillion on health care, or $7,439 per person. The US government spent $2724 per capita in 2004 (>$600/capita than the Canadian government, which has Universal healthcare). In France (ranked #1 by WHO in 2000 for heathcare), the government pays $3926/capita. The US, in that same ranking, ranked #37 in overall health care.

What are we paying for? Well, we're paying for tests that provide profit for doctors and clinics since visits are now paid so little by insurance companies that a doctor loses money to see you. We're paying for extra help in the doctor's office to deal with eleven billion different forms of insurance so he has four admin staff to handle the insurance hassles instead of, say, another nurse and a physician's assistant. I've read estimates where ~50% of our health care costs were related to insurance dealing admin activities. So, we double our bills to have all this private insurance and then pay the middle man for the privilege. Nice job. We're paying, through the nose, for new drugs that may or may not be better for us than the drugs we already had, depending (in some cases) on whether or not one is making a profit from them.

And, in this country, more than 47 million people don't have health insurance or any health care coverage. 47 million put off taking their kids to the doctors or live in fear of what they'll do if one of their kids falls and breaks an arm. Many have jobs that make ends meet, but little more and health and the steps to ensure health are often what falls behind. One serious infection, on bout of meningitis, and families lose their homes, their futures. And they might not get the care they need until too late.

I don't know about you, but that's not acceptable to me. Can health care be better? Yeah. Can it cost less than we're paying? You bet. People all over the world are doing it. For what we pay per capita, no one in this country should be deciding between taking their kid to the doctor and rent.

That's the kind of choice no one should have to make in a civilized society.

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More on Health

I try to catch up, but it just isn't working. Ended up working until late at night for WORK so I'm just now starting my blog. Which means I doubt I'll get it all up before the night's out. Whew!

I mentioned some speculation about unforeseen consequences for our pill-poppin' tendencies in my last blog. But I kind of would like to continue that line of thinking with regards to the whole health care industry. Now, let me preface my opinions with an assurance that I know many health care professionals are dedicated and devoted. I don't intend to imply that problems I've seen are a condemnation of the whole medical profession.

However, there are some serious problems out there, whether they result from insurance issues or financial pressures or laziness - a tendency that exists in most professionals to find an "obvious" answer and then leave there without looking deeper. In certain professions, like space safety, that kind of laziness can get people killed (or at least spacecraft lost). This is also true for the medical profession.

Too often, in my opinion, an obvious answer is addressed without digging for the real cause. Treat a symptom without realizing what the real problem is.

Case in point, my mother-in-law, for instance, has been battling mini-heart attacks since she was thirty-seven (little less than a decade, by the way - yes, my husband's younger). She's gone into the emergency room multiple times. She's fought multiple bladder and other abdominal infections and pains that no one's taken seriously. So, two weeks ago, she went into the emergency room and someone suspected a gall bladder problem and gave her a simple blood test. There it was. Her gall bladder was 19 cm in diameter (instead of the normal 3) and filled to (literally!) bursting with 37 gall stones. And, yeah, the doctor thinks it's been a problem for ten years but no one ever checked.

Now, this is one person, anecdotal evidence at it's best, but can you honestly say you don't know a story like this? Someone calling in to the doctor with their four month baby's coughing but never able to get an appointment, but getting prescription medicine over the phone, only to force the issue and find out the baby now has pneumonia because she'd been given the wrong medicine? When she told me I'd made my baby sick because I'd given her the wrong medicine (that she'd prescribed), I vowed never to go back to that doctor. And I didn't.

A relative's son had surgery for an in-grown toenail. He ended up with a fever that the doctor repeated dismissed over the phone. Fortunately for mymy relative's son, my relative took her son to the emergency room when his temperature topped 103. But not, unfortunately, before he ended up with an infection in his bones that made for three very scary days in the hospital and took six months of IV antibiotics to overcome.

My poor mother-in-law has had a number of doctors that have not ever seemed to delve to her real problems. But I learned something listening to her struggles. I believe most doctors do their best, but, even under the best circumstances, they aren't going to understand your body as well as you do. They're going to know how many people react to certain medicines, but they don't know how you have responded or will respond. When it comes to your health and the health of your family, you had better be an informed consumer and know what's happening and what isn't going like it should.

People don't come with warranties and you can't just toss 'em if they break down. And, for all the uncertainties and unknowns that come with chemistry and physics, it's just a drop in the bucket to what we don't know about biology.

Just sayin'.

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