I’ve grown wary by the run of inane commentaries by Ph.D.’s taking over the NEJM, but this one is actually not bad.
We’ve been talking about how the American health care system is on the brink of “collapse” for the last 40 years. What’s holding it together? Lawrence Brown says it’s the oft-ignored network of safety nets:
The problem with this analysis is that the U.S. health care system consists not of two sectors (private and public) but three, one of which, the safety net, rarely gets proper attention and is poorly understood. The safety net encompasses public and voluntary hospitals, community health centers, public health clinics, free clinics, and services donated by private physicians. Configurations of safety-net providers vary markedly among communities, as does their financing, a shifting patchwork of funds from Medicaid, the State Children’s Health Insurance Program (SCHIP), the federal disproportionate share program, tax levies, foundation grants, state appropriations, commercial payers, and other sources. These institutions often live on the financial edge, but with 11th-hour infusions, they mostly manage to stay afloat. This fact is of paramount importance, for these providers also extend a safety net for the political legitimacy of the health care system as a whole. That Americans who lack coverage can “still get care,” as President Bush recently declared, drains moral urgency from the health care reform enterprise.
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{ 3 comments }
One of the best summaries I’ve read. It aknowledges that there is not a “healthcare system”, that the multiple systems in place work well enough for most people that they don’t like the alternatives, and that a supposed “crisis” that has been going on for two generations, is apparently more stable than it looks and is not actually a crisis.
Every national “system” fails–they all either have captive populations who are not permited dissent or have major outlets for those not served by the system. No system is universally sufficient.
The USSR had the special clinics for the nomeclatura and also an illegal private care system.
Britain has private care backing up the NHS
Canada has the US within 30 miles of nearly every Canadian.
What is our backup here? Well, 14% of people are uninsured and physicians give away 14% of their clinical services. What has prevented “collapse” are all the people in the trenches working to get people care. Whether they are providing free care to an unemployed patient, or on the phone with the insurance company for an employed patient, it is outcome oriented docs and other providers making things happen for patients that keep it all going.
It may be working now, but the tipping point is coming, and “collapse” will occur. My generation of doctor (I’m 55) is geting tired of being dumped on to provide free care. I didn’t mind it in my earlier years, but with my salary going down the toilet, and my expenses going up, don’t count on me, at least, to provide free care. Like all of you non-physicians out there, I need to make a living, support my family, and plan for retirement. As for the new generation of docs, those who look at lifestyle and money before career (no criticism as it’s your life, your choice)- where 2 docs will be needed for 1 FTE – you can outright forget it.
I agree. The “system” has been carried by docs and others giving of themselves to make things work out for the patients that cross their paths. Not being paid for every patient encounter has always been a given of medical practice. But that came with a lot of freedom. The freedom to set your fees for the remainder of your patients and practice by your own lights among them.
Now they have taken away, or are striving to take away our liberties and traditional professional perogatives. The government and insurance companies want us to take orders like employees.
In absence of recipricol compensation in the form of professional independence and freedom, the motivation to give extra bleeds away.
It is the very efforts to “reform” the system that may destroy what makes it work.
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