Wednesday, February 10, 2010

ObamaCare and the Return to Marcus Welby

Obama's urgent need to confiscate tax money to cover everybody's health care is an indicator of how far medicine has come since I was a kid.  His pressing insistence has a basis in the same technology that brings you this blog, and the apps on your iphone, and your music and photos and games and Kindle--and there's no way we'll ever retreat.

Way back in the far reaches of my memory was chicken pox.  It was a disease your mom made sure you got, by sending you to play with some spotted friend, because you needed to "get it over with" lest it strike with greater force once you became an adult.  Kids don't get chicken pox any more. They get MMRV shots as babies, ending the social delight of intentionally exposing youngsters to "childhood diseases" that are no more.

But when my siblings and I were in the midst of "getting it over with," the pediatrician, as part of his normal duties, showed up at our front door.  I vividly remember him--a stranger to me, really--coming into the bedroom I shared with my similarly-stricken sister, his leather black "doctor's bag" in hand; his cold stethoscope on my chest.  They used to call those visits "house calls."  They didn't cost extra.

In those days, families paid for just about everything outright.  You got a bill from the doctor; if you couldn't pay it all at once, you worked out a payment plan. Yes, there was insurance, but it was private (Blue Cross), not very expensive, usually only for really catastrophic situations, and most people didn't have it.  Certainly no employers paid for it.

Until the 60s, when governments and unions used coverage for bargaining and as perks for employees.

Then, in 1965, President Lyndon Johnson, in a fit of liberal largesse, sought to provide retirees with government-sponsored health coverage.  At that time, most people retired at age 65 and looked forward to rapid decline, surviving at most another decade, as US life expectancy was only 70 years.  Medical care was just starting to get technical; pharmaceuticals were becoming more sophisticated and proprietary.

Without universal retirement plans, a new class of oldsters who weren't being taken care of by newly mobile children got attention in Johnson's "War on Poverty" after exposes about their subsisting on dog food.  Medicare filled in where Social Security left off, followed by Medicaid, the national program for non-elderly poor. But the key there is that it's not federally-managed--each state controls its administration locally. 

Really, it's only been in the last 20 years that HMOs and employer-subsidized health plans became de rigueur, severing all direct connections to local doctors and inserting middlemen at faraway desks, insulated from customers by powerless phone personnel.  Ask a kid what a doctor's bag looks like--he'll shrug.

Do we customers like dealing with huge corporations who determine our premiums, our co-pays, our deductibles?  Do health care providers like that their fees are negotiated and set by the same corporations?  Ever get an "EOB" (explanation of benefits) from a health insurance company that lists a doctor's charge, and then the "adjustment" he makes because the insurance company decided his fee was more than they've decided to pay?  What is this game?

It's the stuff of consumer backlash.  Because if taxpayers know one thing, it's that adding layer upon layer of government bureaucracy onto a system that's already rife enough with regulations, strategies and middlemen isn't going to streamline anything. Instead, it will complicate and worse, cost much more.

By the way, I'm incredulous that thousands of American citizens die each year due to inability to afford health insurance.  Emergency rooms do not turn away indigents.  Medicare, Medicaid and local governmental programs do exist. And private charitable institutions do a tireless job. College and university students have campus resources. And 1,200 free clinics, staffed by generous physicians, exist in every metropolitan area.

Can we ever go back to the friendly Dr. Welby of the olden days? Of course not. We now demand medical science provide magic pills and room-size equipment that hardly fits in the traditional physician's bag.  We seek specialists for second opinions, and form our own analyses by scouring the internet, sometimes spurring expensive lawsuits, served by eager lawyers.  Health care is increasingly complicated, and we now expect to live a lot longer than before. Into our 90's, actually. 

The US spends 16% of its GDP on health care; more than any other modern country.  It's not going to drop--either with feds controlling potential profit or with the status quo, because free enterprise is already so tamped down by government regulations and laws that shape the structure of the insurance industry. What's the answer? I'm not in a position to speculate, but getting back to catastrophic insurance coverage, with individual management of relationships with doctors would be much better than the interminable phone waits and impersonal rulings on payments that we all now face--which would be much, much worse controlled by the biggest bureaucracy of all, the federal government.

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