What would a smart, compassionate, affordable health care system look like?

One year after passage of the Patient Protection and Affordable Care Act, the debate roars on, in Congress and everywhere else. And these debates often revolve around a big question, even when it is left unspoken or implied: Is health care a basic human right?

In 1990 I made a quantum leap from practicing in the Navy’s single-payer, universal-coverage health care system into civilian pediatrics. Having been insulated from the profit end of health care for almost a decade, the move to the U.S. healthcare system of haves and have-nots turned out to be a culture shock.

My first civilian job was at Wood River Community Health Center in Rhode Island, and one of my first patients was Jennie, a three-month-old who had been placed in foster care because of her mother’s drug addiction. Being in foster care meant being on Medicaid.

Poor children on Medicaid have several strikes against them. Not only will a provider often lose money by seeing them, but these children are on Medicaid because they are special needs patients, or in foster care because of abuse and neglect, or from impoverished circumstances that have put them at risk of malnourishment, or exposure to lead or smoke. These are the most labor-intensive patients in a pediatric practice. How well they are cared for is the measure not only of a pediatrician, but also of a society.

By the foster mother’s description, Jennie had a generalized seizure – a convulsion – at home. Her physical exam was completely normal. I called the only pediatric neurologist in the state at that time and faster than I could say “foster care” he understood the kind of reimbursement he could expect. He insisted he did not need to see the child or do any tests. I was shocked. No EEG? No imaging studies? This was the same doctor who routinely performed unnecessary but very expensive EEG’s on every insured headache patient he saw.

“What’s the point?” he challenged. “The mother is a drug addict; this was a withdrawal seizure. You don’t need to rule anything else out. Load her up on phenobarbital.” Phenobarbital is a sedating drug that back then was commonly used to treat seizures in children, but we usually looked harder to document and find a cause for the seizure before we settled into therapy – especially in a three-month-old.

I was angry and backed into a corner. I told Dr. Do-Little that if he would not see her then I would refer her to the ER at the Rhode Island Hospital, and let them contact him. He was on the staff there and would have no choice but to respond. Do-Little begrudgingly relented but got his way in the end. He was rude to the foster mother, and did only the most cursory exam on the child. He started medication without doing any tests.

Practicing pediatrics in the Navy meant I always had the resources to deliver state-of-the-art care – and no excuses not to. But here, no matter how strongly I felt that my patient should receive a certain service, I might not be able to get it for her because of her inability to pay. It was the first time in my medical career that I knew what a patient needed, and had to settle for something less.

Did Jennie deserve better? Did she have the right to the same health care as, say, my daughter? These are awfully solemn questions for public discourse, and are likely to keep us running in circles through a haze of abstractions and ideology. We need to think less like judge and jury over who deserves health care, and more like stewards.

As a nation, even in this recession, we can claim remarkable prosperity relative to the rest of the world. (Nowhere is this truer, incidentally, than in the highly profitable private health care industries.) More inspiring, however, are the brilliant medical advances that continue to emerge from our academic centers and teaching hospitals. This drive for new knowledge and innovation in the pursuit of health and healing is our real treasure – America at its finest. It has always been the best in people, not greed or profit, that has driven meaningful medical progress.

Yet the system isn’t working for us. We are spending too much, and getting too little. We need to be better stewards of our medical riches. We need to see ourselves as stewards, and ask questions from that perspective, rather than who deserves what slice of the pie.

So let’s redirect: Given our considerable medical resources, what moral responsibility do we all share in the fair, prudent, and just allocation of these resources. From this position of stewardship, we are likely to ask more practical questions: What would a smart, compassionate, affordable health care system, released from the stranglehold of special interest, look like? What preventative and therapeutic services should it deliver? What responsibility does the individual hold? Once we have a clearer picture of what we expect of ourselves and the system, we can turn to how we can make it affordable. Stewardship gives us direction and purpose. If we can tune out the noisy rabble-rousers, reframe our questions, and commit to responsible conversation that is grounded in our own common sense and decency, I believe we would find much common ground, and make a lot more progress towards a just and cost-effective health care system.

Maggie Kozel is the author of The Color of Atmosphere: One Doctor’s Journey In and Out of Medicine and blogs at Barkingdoc’s Blog.

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  • http://twitter.com/sdietrich17 Sharon Dietrich

    I have worked in a non profit clinic system for 25 years, and the story Dr. Kozel relates is right on the money.  I have experienced situations like this many times, as have my colleagues, and it is now increasingly the case, given the cut backs in health care for the underinsured in our state.  Whether the patient is without insurance, or covered under Medicaid for whatever reason(foster care for one), we deal with specialists not wanting to see them, even when they would see an insured patient in a New York minute.  This necessitates contemplating sending the patient to the hospital to force the specialist to see them, even when it is not deemed appropriate for them to be sent to the hospital.  Or, sending the patient to the large teaching hospital 4 hours away, since this institution has no choice but to see them, even though they are inundated by these patients, since many of the private hospitals have the same policy as the private physician in this case.  The system is broken.  I agree that we need to ask ourselves what we want and expect in a health care system.  But there should be no debate in this country about whether health care is a right or a privilege.  Health care is a right, it must be, it is.  How can we be guaranteed LIFE, liberty, and pursuit of happiness without health care??  Anyone who thinks differently has their own private health care plan, and is basically saying:  “I’ve got mine, you get yours”.

  • Anonymous

    It’s terrible to think that this trend is continuing in the wrong direction. I have a feeling the Obama health initiative will be over turned at some point and those that were uninsured with go back to being so. Awful to think that a person’s life has any sort of dollar figure attached to it, but it’s the system we live in!

    • David Huss

      First note: I’m not a tea partier and I do think Obama is doing well given what he inherited, however HCR does nothing to prevent what this author described. In fact it will make it worse.

      The little girl mentioned in this article had “insurance” and in fact had the exact same sort of insurance that many Americans will gain under the health care reform legislation, medicaid. Medicaid reimburses primary care doctors so poorly that, if you were in private practice (and not a government funded clinic as per the author) you wouldn’t be able to keep the lights on/stay in business. As such in areas where there are large numbers of medicaid patients won’t attract doctors. Further, where there are a mix of patients, specialists (and to a degree primary care doctors) will cherry pick those that whose insurance pays more.

      So with the current HCR more people will get crummy insurance that few specialists will take. Also, as the government further decreases reimbursements (also a part of HCR) this shortage of specialists taking the insurance will only get worse. So the Obama health initiative (in my opinion) will do nothing to solve this issue.

      Now one solution to this is to try to do more as PCP’s. The fact is, doctors now have easy access to tons of information through internet-based resources (UTD, CDC webpages, IDSA guidelines) such that, if we don’t immediately know what the best practice is, we can find out pretty quickly. Obviously this doesn’t work with testing (like the EEG mentioned in the article) but can still remove the need for some specialist referrals.

      As for things like EEG’s, technology continues to get cheaper, more automated, and easier to operate. For example, ultrasounds are becoming commonplace in the primary care setting enabling all sorts of quick exams. While EEG’s aren’t (they take some skill to interpret) this may change in coming years. Take home 24-hour EEG units already exist (eliminating the need for a monitored EEG/sleep study) and eventually software will make the results easy enough to read that a primary care doctor can interpret them. Perhaps once specialists realize that primary care docs can do more they’ll be a bit more cooperative.

      • Anonymous

        Spot on!

        The resolution must be led by the physician and the outcomes must be decided in advance. As that will not happen then you and every one of us must live with this Patient Protection and Affordable Healthcare Act which is neither. That should be no surprise as it is a political solution that favors those that curry favor.

        What you should really be concerned about is the coming Government actions that will seek to divide the specialists and the primary care physician with the result of legislating all of them to accept Medicare and Medicaid. This is exactly what the insurance companies did quite successfully with “Managed Care” which also, by the way, was neither.

        PCPs better take note of this well worn tactic of “class warfare”. Fall into the trap and you trap yourselves as well. It isn’t about money in the end; it’s about the freedom to practice in the manner you choose within the boundaries of the “standard of the community”. Once they take that away, then we are nothing more than the sheep we have shown ourselves to be.

        Indeed, if G-d hadn’t meant us to be slaughtered, he would not have made us sheep!

        Mitchell Brooks, M.D.

  • http://twitter.com/pttennisdiva Knees Software

    Excellent comments.  How can we can we get past the “rabble-rousers” and onto common sense to create a reasonable and functional health care system in this country?

    • Anonymous

      Get in the game, get involved! Speak out. Call your Congressman/woman. Find common ground and don’t name call. Remember that you are entitled to your own opinions but not your own facts, and listen; above all listen.

      Appreciate your positive comment.

      Mitchell Brooks, M.D.

  • Matthew Mintz

    While I appreciate your frustration that a patient in need did not seem to get the care she deserved, I am not sure you have answered your question “what would a smart, compassionate, affordable health care system look like?”  Given that you start out this post with your Navy experience, you imply that “a single-payer, universal-coverage health care system” is the answer.  However, the Navy is a bad example for arguing for a single-payer system.  Navy medicine costs far, far less than what single-payer universal coverage would cost.  Military personnel are far more healthier than the average American.   They can lose their job if they don’t pass a fitness test. Now I realize that military docs also see dependents, who may be less healthy.  That said, it would be illegal for any private insurance company to require a fitness test for the primary beneficiary  Secondly, military medicine is well funded because it comes from the defense budget. I am not an economist, but stories about $100 toilet seats suggest that the Pentagon doesn’t skimp. A much more appropriate example would be the VA. In it’s defense, the VA has outstanding outcomes (blood pressure control, diabetes, etc.) and any Veteran can get their health care in the VA.  However, the VA has some major restrictions: almost all meds have to be generic, limited availability of specialists, waits to get diagnostic procedures, etc.
    Most curious is your statement “we need to be better stewards of our medical riches.”  While I agree with this statement, you criticize a pediatric neurologist for doing just that.   The patient had Medicaid, a government funded insurance. I am not a pediatrician, so perhaps I have this wrong, but was he incorrect in his diagnosis of a withdrawal seizure? Was an EEG really necessary?  Is there solid evidence for performing a EEG to rule out other causes of seizure in a 3 month old whose mother was addicted to drugs, when the most likely diagnosis is a withdrawal seizure? If the answer to these questions are “no,” then was the neurologist you condemn doing exactly what you are asking for, i.e. being a good steward of our resources?  
    In a well funded, single payer system (like the military), we might be able to have a smart, compassionate, affordable health care system. Unfortunately, in order to provide this to everyone, we would either need to substantially raise taxes or start to ration expensive services or possibly both. The real question is not what would a compassionate, affordable system look like, because I think most physicians have some idea of what this would look like.  The real question we need to ask is what price are we willing to pay for this? If tax increases are a non-starter (which seems to be the case for Republicans), then what are we willing to give up?  Branded prescription medications? Most MRI’s? EEG’s for infants born to addicted mothers that suffer a withdrawal seizure? 

    • Anonymous

      1.  We can change laws to make it legal for fitness tests.
      2.  We can vote for representatives that would fund the healthcare system we want.
      3.  Young men don’t see doctors unless they are dying.
      4.  Is it more important that grandma with alzheimer’s gets her mammogram and her cholesterol medication or that infant gets an EEG?
      5.  We already ration expensive services.  An infant with a drug addicted mother with good insurance would have gotten the EEG so the doctor can make a profit.

    • http://www.facebook.com/people/Maggie-Keavey-Kozel/1383572933 Maggie Keavey Kozel

      Your point is well taken – the military system did not ground itself in cost-effectiveness. My point however was not that that is the system we need, but that things can be different.  We don’t have to accept the notion that health care is a commodity. This is not some crazy socialistic idea.  But it makes no sense to me to try and figure out how to pay for it until we figure out what we want.  So my article was a call for a change in mindset – to one of stewardship – before we approach the nitty gritty of  what reform should look like.

  • Anonymous

    I admire your passion and your sense of personal professional responsibility. Furthermore, your sense of frustration is easy for all of us to appreciate but it appears to me that you may wish to consider several things.

    First, with respect to the Navy, you are speaking to a very defined cohort that is an apples to oranges comparison to the 310 million people in the United States from diverse cultures and disease state sensitive backgrounds.Secondly, you stated that in what manner for which such children are cared “is the measure not only of a pediatrician, but also of a society.” I couldn’t disagree with you more and this goes to the very root of your discourse, and the solutions you fail to provide. This child is a measure of her mother and her father, not of any pediatrician and not of society. If we do not start accepting personal responsibility for our own health, there will be no money to treat anyone. The fault, dear doctor, “lies not within our stars but within ourselves”.This very issue is the stewardship of which you so eloquently speak.

    Thirdly, your comment regarding who deserves a slice of the pie is, and you will excuse me as I cannot find a softer word, unsophisticated. Permit me ask you a question. If you have a 3 month old daughter who has seizures of unknown origin and she comes into the hospital at the same time as the child about whom you speak, who should get the care if there is only a certain amount of money left to provide the treatment and diagnostics necessary in these cases? Do you not have a “special interest”. Will you give leave to the other woman’s child without even mentioning the social circumstances surrounding the etiology of that child’s seizures so that your child can receive the care? Far-fetched scenario…ahh, not so in the future. Expanding and growing demand for limited resources and limited funds begets rationing. EVERYONE is a special interest and has one. 

    Last, you provide no solutions to the myriad problems we face. While I laud your commitment and your passion, you provide no process to achieve defined outcomes. You may wish to go to http://hotnationtalk.com/?cat=4 and read the blog regarding “Ten Principles for Affordable Healthcare” or visit the archives on this site. It is far from perfect but can serve as a straw man for serious discussion.

    I thank you for your sincerity and your firm resolve to work on behalf of your patients. It is admirable.

    Mitchell Brooks, M.D., FAAOS

    • Anonymous

      “This child is a measure of her mother and her father, not of any pediatrician and not of society.  If we do not start accepting personal responsibility for our own health, there will be no money to treat anyone.”

      Perhaps instead of wasting taxpayers money on foster care, we should abandon the child.

    • http://www.facebook.com/people/Maggie-Keavey-Kozel/1383572933 Maggie Keavey Kozel

      My point was not to say we should replicate the military system, but rather to point out that there are much better ways to deliver health care than our current civilian one.  But we need a change in mindset before we can achieve a substantive change in reimbursement methods.  My point was about viewing health care as stewardship rather than selling a commodity, which is what we now do. And I must strongly disagree with you on your final point.  A three month old is not a measure of her parents.  Her parents’ behavior is a measure of them – an entirely different matter.  And honestly  I cannot follow your ER scenario at all.  It seems you are talking about medical triage, and that has its own rules apart from socioeconomic circumstances. 
      I am trying hard to overlook your suggestions that I “consider” factors that I have actually lived and worked with for twenty years, or that you appreciate my sincerity despite how “unsophisticated” my ideas are, or that you have references I can turn to so I can be part of a serious discussion. But it is hard to not bristle at the condescension.  If you dismiss the idea that mindset has a role in our healthcare debate, then so be it. Stick with that. And good luck.

      • Anonymous

        The reproduction of a child IS the responsibility of the parent(s)! That’s the problem-there are no consequences to behavior that is pernicious to society, and please do not tell me that my comments apply to the child; they do not and never will. Should you choose to speak to mind set, then, indeed my mindset is firmly placed in the role of personal responsibility as a key factor in lowering the cost of healthcare delivery. An infant is not responsible for the consequences of its birth or the behavior of its parents; a civil society is; the question is, to what extent and to what cost, over time, to the society as a whole. This goes directly to your point about stewardship.

        I never took your point to say that the military system speaks to replication. One of the issues in trying to determine what is best for healthcare is not creating a one size fits all structure for a diverse population.

        As to my choice of “unsophisticated”, I apologize for having offended you, as I made assumptions I should not have. Please know that offense was not my intention. That said, you did not answer the question posed in the context of that poorly chosen word. As to your being part of a serious discussion, it is obvious that you are. I understand, though, how you might have formed that conclusion. I apologize again. 

        Regarding the ER, you are correct, I most certainly am speaking to triage, though I am very aware of its controversies. It is the only logical way in which ERs are going to be able to handle the increased number of patients that will find their way to their doors as a result of adding 40 million new patients to the insured population. The reasons for this are multiple but the experiences in Canada, specifically Ontario, will mirror in smaller numbers what will happen herre and will do so for the same reasons.

        Last, mindset is the centrality of the healthcare debate. When you peel all the layers back, the nub, the kernel, if you will, is about whether or not healthcare is a right or a responsibility; whether it is for a government to provide, as opposed to promote, the welfare of its citizens or it is for the citizen to be a proper steward of their own health with community assistance if needed.

  • Anonymous

    It is unclear whether a smart, compassionate, affordable health care system would result from a single payer.  Acknowledging the transition of practicing medicine from the military context of unlimited resources to practicing medicine as a civilian physician restricted by the finite resources indicates that military ethics of the military physician are clearly different from the ethics that govern civilian medicine.  The unquestionable availability of resources in the military should not interfere with the practice of medicine and the compassion shared by the physician to his patient.  I appreciate the opinion of DR. Kozel, but I would like her to emphasize that the fundamental difference in military health care versus civilian health care is the process that leads to the absence or choice of different health care systems.  This idea was promoted by Dr. Brooks in his article entitled, We Need a Single Payment System Instead of Single Payer.

    • http://www.facebook.com/people/Maggie-Keavey-Kozel/1383572933 Maggie Keavey Kozel

      I am not sure I follow how practicing military medicine involves a different ethic than civilian medicine.  I feel I practiced with the same ethics in both settings, but had fewer obstacles in the military system. The point I was trying to make is that there are other, better ways of delivering health care, but it requires a mindset change – to one of stewardship. And we have to determine what we want our health care system to deliver before we decide the method of payment that is most likely to achieve our goals.

      • Anonymous

            Dr. Kozel, I believe practicing military medicine involves a different ethic than civilian medicine because of the nature of the population served in either one.  In the military, the population is more homogenous than the civilian population because there are specific standards military personel must meet.  By and large the military does not contend with issues around poverty and does not have to worry about payment method.  The example about the baby who is on medicaid is confusing because medicaid is a single party payer as is the military.

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