REFLECTIONS:   ON HEALTH CARE REFORM

This article is about the current health care reform debate sweeping the country.  Bottom line, we urgently need health care reform. It is unfortunate that the debate has been marred by mis-information, ignorance, and lies. The debate would probably proceed in the right direction if our government can realize that they are not the appropriate agents for the reform. They should play the role of catalysts.

THE FORMULATION

 Our government officials are highly intelligent and dedicated public servants. I am personally grateful to them for serving under the difficult circumstances facing our generation. I applaud them for wanting to tackle the difficult issue of health care reform. However, our legislators should not be the ones to formulate a health care reform.

Most of our legislators have never been without insurance. Most have never been poor. They have never been sick and not get care—the best care. They have never had their insurance canceled when they need it the most. They have never had a heart attack, stroke or a car accident that results into total disability and yet turned down over and over again when they apply for disability. They have not had a mother or father that needs nursing home or assisted living and cannot get in because they did not pay into social security. This happens frequently even when the sick person has no one to care for them at home and have no income except in some instances, food stamps. I can go on forever but you get the picture. I am employed in a hospital as a hospitalist. I take care of the un-insured. I share their pain, their grief, their hopelessness, their fear, and feeling of abandonment. Let me share just on e example. Recently, I took care of a nurse that spent her entire life caring for other people. She lost her insurance when she became sick and had to resign her job. She stayed in the hospital for more than two months because she had no one to take her home and care for her. She had no Medicaid or Medicare and so we could not arrange nursing home placement. We also could not arrange for rehab when she was strong enough to benefit because she had no insurance. Finally, one of her daughter-in-laws who could hardly feed her family came and took her “home”. We arranged for hospice to help with her care. When hospice went for home visit, they found her alone in a mobile home without light or water. She died in less than a month after leaving the hospital. I have countless stories like this. Having our legislators reform our health care system is like asking my five year old son to describe Einstein’s Theory of Relativity. The moral of the story is that we need health reform championed by people who know about health for the un-insured or under insured. A lot of these people see what they do as their calling and deliver whatever care they can give with passion. They should be at the for-front of any health care reform.

DELIVERY AGENTS

Secondly, the government must not be the delivery agent for the new system. In my community, only one or two doctors accept Medicaid. The system is so dysfunctional and beaurocratic that doctors have abandoned it in massive numbers. I encountered it for less than a year and had to give up my job because of it. Whenever a prescription is written for a patient and they take it to their pharmacy to fill, they are told that it needs to be pre-authorized by their doctor. The doctor or doctor’s nurse contacts the Medicaid office, waits on the phone forever, only to be told that a form will be faxed to them to fill out to justify the need for the medicine. After completion, the form is faxed back only to be told that the request is denied. This happens to the point that you begin to wonder if the program is a fraud. An example is one of my patients crippled by rheumatoid arthritis and was having unbearable pain.  On one occasion, I had to threaten to admit this particular patient to the hospital and have Medicaid pay thousands of hospital bills instead of paying few dollars for outpatient management. They finally gave in only to pre-authorize her medicine for only two weeks. If our government cannot manage Medicaid effectively at its condensed size, can you imagine what will happen to a more gigantic all encompassing system of health care?

The welfare system is another example of what happens to a program ran by the government. The most outstanding result of the welfare system is the massive production of kids ever known to mankind. Some teenagers are now making careers out of motherhood.  Many of the welfare kids are in prisons instead of schools.  Many are cut up in the destructive drug business. Many are professional criminals. Many languish in jails. Many are not contributing members of society and yet we finance every aspect of it. The system has produced the most system dependent, system destroyed, and system deprived human beings in the greatest country in the world. A government program has created a generation rendered incompetent by public assistance---a system we created and now despise and want to disown. Victoria, my pre-teen daughter was shocked that an unmarried teenager that fixes her hair was pregnant. She came to me looking for answers and all I could tell her is that during the tax return season , this teenager will receive a refund, and I who have three kids in private school will be told to pay back more because I chose to work and marry. If the unemployed teen mother and her child/children get sick, the system pays all their bills while the insurance companies fight or deny most claims submitted on behalf of the insured. Victoria typifies our politicians. She, like our politicians are sheltered from the realities of the real world. The Victorias’ of our government should not be at the forefront of the health care reform.

IF NOT THE GOVERNEMT, WHO?

The government needs to set up a health care reform commission. The commission should spend 3-6 months formulating the nuts and bolts of the health care reform. The commission should comprise of doctors, nurses and various non-profit agencies that deliver health care to the un-insured or underinsured. The doctors I am referring to are the ones in the rural areas where most people are left out due to unavailability, unaffordability, or accessibility. Many of them know firsthand, the challenges involved in caring for the underserved and uninsured. They know what it will take to expand the compassionate care they already deliver. They know what it will take to accommodate those left out by the system for one reason or another.  In my town, I know a Dr. Hazelwood who cares so much that he will do everything possible to make sure that a deserving indigent patient receives care. I also know a Dr. Daniel Gregory who is the Director of Care South; a government sponsored Rural Health Clinic. He has opportunities to pick more glamorous jobs but stays with the clinic because of his commitment and dedication to the population served. I also know of Mrs. Cathy Baxley and Sharon Dubose, directors of the two free clinics in Darlington county, South Carolina. They are angels to the un-insured. These people and numerous others like them know the industry so well that I highly recommend people like them to become members of the Health Care Reform Commission (HCRC) I am proposing. 

In a nutshell, the Health Care Commission should comprise of doctors and nurses and health care delivery professionals with real life experience that speaks louder than the noise being generated in Washington or town hall meetings. These people are the Mother Theresa’s of health care for those without access. Their jobs are their calling. We can trust them to deliver a solid unbiased health care reform package. Every community has these kinds of people. Those people that serve without expecting much in return.  I will suggest that they come up with ways to expand the care and services provided by community and rural non-profit clinics and make them accessible. The Governments role should be to decide how to adequately fund these clinics as agents of reform for the government. Commission members should be paid their salaries and be promised a return to their jobs upon completing their task.  My suggestion would be to increase the numbers of community health clinics and put incentives in place to attract providers to these clinic. The clinics can have a few doctors in charge of mid-level providers who will do hands on care and consult supervising doctors and specialists as needed. If we put NPs at the entrance to the doors of health care, this country will see a big difference in the quality of health care delivery and outcome. Nurse practitioners are great teachers of life style changes and preventive care. There is extensive research supporting this claim. The commission should also figure out how the patients of the Community Clinics can obtain specialty care when needed. Currently, many of them end up sicker because they could not afford a specialist or essential medical equipments like Bi-pap for sleep apnea. The clinics should have urgent care components that will see those with non-emergency illnesses. Each clinic or a group of clinics in close proximity should have an urgent care center that will decongest emergency rooms and free them up for medical emergencies. Currently rural clinic patients are told to go to the ER for urgent care cases because it will take weeks before clinic doctors can see them. Another area of concern is insurance companies. It is imperative that a watch dog group like the Joint Commission for the accreditation of Hospitals be set up to monitor the fraudulent practices of the insurance companies and punish offenders. The commission should be empowered to set up a check and balance system to make sure that the insured receive the benefits of the premium they pay when they get sick. If the set up of such commission is not feasible, everyone American should have the option of being insured by a government program that will guarantee payment when appropriate care is rendered. Currently, Insurance companies delight in getting rich from premiums but will do everything possible to deny payment for the care of their patients. Similarly, doctors’ office visits are now a game of numbers. Most providers are spending 5-10minmutes for each patient encounter. They are not spending enough time to listen, talk, teach, and explain care. Patients are therefore not getting the care they are paying for and deserve. Many providers are therefore getting rich for mediocre services. Providers must be held accountable by using quantifiable outcome measures.

WHO SHOULD RECEIVE CARE

Anyone who is handicapped or disabled. Employed citizens who are not making enough to afford health insurance but contribute to keeping the system afloat.  Able bodied men and women must not be allowed to reap what hard working citizens are sewing. People must contribute through formal employment that helps  to sustain the system or be made to volunteer in public programs. We have less and less people contributing and more and more people wanting something for nothing.  As a nurse practitioner, I have worked in an Emergency room setting where majority of the un-ensured receive primary, emergency, non-emergency, urgent, and non-urgent care. A lot of the patients are drug addicts and alcoholics who abuse the system and make a career out of system abuse.

TO RE-CAP

 1. Our government cannot run an effective healthcare system. It will be a nightmare for all involved. The best predictor of future outcome or behavior is past experience----welfare system, Medicare, Medicaid, the postal service and the like... I am sure you may have encountered other beaurocratically crippled government systems or programs.

2. The senators and congressmen and women should not be the originators and formulators of a new healthcare system ----they don’t have enough health care experience to handle such gigantic and complex reform. Moreover, many have been bought completely by private interest. To them, public interest is at the bottom of the pile.  That’s partly the reason they are being mobbed at town hall meetings.  Majority of the people know deep down that we need health care reform but they do not trust our government.  Their role should be to review the commission’s recommendations, ask questions and cast an intelligent vote at the end.

3. It was a mistake to get the public involved. The so called peaceful revolt coined by my heroe, Senator McCain is not about health care reform or President Obama. Health care Town Hall meetings became an opportunity for people to vent long held frustrations about a government perceived as “no longer of the people, by the people, for the people.”  Our leaders MUST realize that why few of us may seem angry about health care reform, all of us are angry, afraid and distrusting of whatever our government is doing or promises to do. The government that cannot fund health care reform for its citizens voted overwhelmingly to spend and continue to spend unfathomable amount of money to fight the war in Iraq. The anger being expressed in Town Hall meetings reflects public perception of our government. A lot of the attendees mean well but may not have done their home work or know enough about the health care field to be objective. Most of them are radicals who represent groups that despise the government. Most of them have no education in the health care field, have not done their homework, and may not have enough logical thinking ability to handle such complex subject. What happened to doctors and nurses? I see career TV commentators being interviewed about this issue and hardly any doctors, nurses or health care administrators. Do they not matter?  Isn’t still their industry, their area of expertise? Don’t we think that asking appropriate health care professionals and experts to  spearhead our health care reform is like asking Victoria, my twelve year old to head a forum on facebook, twitter, text-messaging, iPods  and the whole computer age gadgets. Let’s get the right people involved, get the job done and move on to the next debate. I think that the task is challenging but not