6 Myths Framing the Health Care Debate
The following is a guest post from Dr. Doug Iliff, a family physician who practices in Topeka, KS.
Myth 1: President Obama is trying to pull a fast one. He wants to ration care based on medical evidence. In fact, medical services are rationed now in any number of ways – including, but not limited to, ability to pay, insurance approval, location, transportation, attitudes of relatives and competence of medical professionals. Americans don’t get upset at rationing of BMWs or Viking ranges. Pacemakers are a horse of a different color.
Myth 2: medical care is a private service business, like the local donut shop. Do you like care or glazed? In fact, the health industry is so big, and often so monolithic, that it has become more like your local utility. When it comes to utilities, Americans get pretty goosey about cutting off the juice. This issue has not been settled yet, but it doesn’t take a weathervane to know which way the wind blows. Once medical care is deemed a utility in the public consciousness, and the pipelines run short of gas, rationing is inevitable. Ask your grandparents about life during Word War II, and see Myth Number One.
Myth 3: Physicians are disinterested with regard to cost-effectiveness. In fact, every one of us makes decisions daily that remove money from the wallets of our patients and insert it into ours. A professional is an individual who works with little or no supervision, in the service of a client, with only an internalized ethical standard preventing him or her from taking advantage of an asymmetric power relationship. And the decisions of physicians – largely in those specialties where new procedures and technologies require ad hoc reimbursement determinations, or where restricted residency slots create barriers to entry and cost competition – are bankrupting the country. Often these decisions are blamed on lawyers and defensive medicine. I think greed and cowardice play a part too.
Myth 4: We’re smart enough now, or will be soon, to consistently make “best practices” decisions in our exam rooms. In fact, we aren’t and never will be. Dave posits a good example: for that basal cell on your face, is it a curettage for $250, which leaves a white divot and a 5% chance of recurrence, or a Mohs for $2,500 which is invisible with a 0.1% chance of recurrence? Forget “number needed to treat” or “years of quality life expectancy” for choices like that. Who gets to choose? And who gets to pay?
Myth 5: Consumer empowerment, in the form of Health Savings Accounts, carrot-and-stick incentives from employers, or whatever, can save us from ourselves. The key question is this: with or without or consent and/or cooperation? I will take it as a fact, based on being the medical director of a minor emergency clinic for 23 years, that one-fifth of the population has adequate insurance or money but still chooses to practice “breakdown maintenance” when it comes to their health. Medical home? Fuggedaboutit. What are you going to do with these knuckleheads, and the many other varieties who sabotage their bodies on a daily basis? I remember from my boyhood a Life Magazine cover displaying thousand of communist Chinese doing mandatory morning exercise in Tienanmen Square. That would be my personal solution, but somehow I think I’d get lynched before it was implemented.
Myth 6: We’re in a war between Republicans and Democrats, capitalists and socialists, and to the winner belongs the future of health care. This is a logical fallacy (“false dilemma”) which omits consideration of other reasonable alternatives. Republicans and Democrats are Tweedle-dum and Tweedle-dee. In fact, Americans of all political and philosophical persuasions are increasingly locked into a mindset of radical individualism, of personal rights without commensurate community responsibilities. This is the back story of this debate, and politicians may not be up for the challenge.
Optimism has worked pretty well for me over 60 ears, although I’ve been mugged by reality and have the scars to prove it. I agree that all of these are more-or-less myths. But I won’t be sucked into a reductio ad absurdum: Taken uncritically, the sum of these myths is that the cost of health care in inevitably going to bankrupt America, and there’s not a doggone thing we can do about it.
I’m not smart enough, wise enough, or clairvoyant enough to predict the final solution. But one way or another, the polis will accept some limitations on their desire for unlimited benefits, some responsibility for their own actions, and some requirement for wiser shopping and sharper questions – all in some way compatible with the unique character of Americans.
One way or another, primary care is going to be in the middle of that solution. I’ll probably be in a rocking chair by the time we figure it out. In the meantime, there is no excuse for family physicians not to be doing well (or at least better) by doing good.