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Health-care reform: What happened to the ‘wisdom of the American people’?

At the end of 1999, the U.S. economy was the envy of the world. The Dow Jones was over 11,000 (now 9,600) and the NASDAQ was over 4,000 (now 1,970). Equally impressive was our federal government’s financial condition: For the first time since 1969, the federal government reported a budget surplus in 1998 and 1999. Even during those “good times,” however, our country failed to provide universal health-care coverage for all citizens: Approximately 44 million people were uninsured, and millions were underinsured. The time seemed right for our political leaders to guarantee basic health care for all citizens.

From my vantage point as an emergency physician in 1999, our country needed to reassess its priorities. The emergency department served as the only safety net available 24 hours, seven days a week because of federal legislation guaranteeing all emergency department patients access to medical evaluation regardless of their ability to pay.  It was, however, “limited” access: There was no assurance that you would be able to find follow-up medical care without some financial guarantee.

The Institute of Medicine estimates that approximately 20,000 patients die each year because of lack of health insurance. Here is one of many examples. In December 1999 I cared for a 52-year-old man who developed chest discomfort while working. He had just started a job that week. According to a fellow worker, the man stated that he didn’t feel well and then collapsed. Paramedics responded and determined that he had suffered a cardiac arrest; they attempted to resuscitate him and transported him to a hospital where I was the emergency physician on duty. Despite our best efforts, we were unable to save his life.

Delayed seeking care
His wife arrived 30 minutes later, confirming that he had started a new job that week. He had complained of some discomfort intermittently over the past 10 days but delayed seeking care because he had no health insurance before that week. He made an appointment to see a physician as soon as he started the job, but, unfortunately, his appointment was not until the following week.

With the 2000 presidential election less than one year away and a rosy economic scenario, the timing seemed right to focus the public’s attention on the inequities of our health-care system. A group of emergency physicians, including the editors for three leading emergency medicine journals, agreed to publicize the inequities of our health-care system, emphasizing the very limited nature of the safety net. We wrote an editorial that was published in all three journals early in 2000 highlighting our concerns regarding the inequities of our system and the need for change: “Our society’s failure to provide universal access to essential health care violates the ethical principle of distributive justice. This principle requires a fair allocation of health care resources among members of society.”

Neither party provided leadership
In that editorial we urged the presidential nominees, George Bush and Al Gore, to present their plans concerning the uninsured problem and offered to publish their proposals. Sadly, neither candidate nor their representatives indicated interest in presenting their views. Despite a budget surplus and a healthy economy, neither political party provided leadership necessary for health-care reform.

Politicians often allude to the “wisdom of the American people.” Some of us questioned what happened to that “wisdom,” as well as the wisdom of our political leaders in 2000.

Fast forward to 2009. Our economy is struggling to recover from the worst recession since the Great Depression. There are now more than 45 million uninsured and another 25 million underinsured. Health-care costs continue to escalate, as does the federal deficit and debt. The special interests have again attempted to derail reform with both old and new scare tactics: the usual catchphrases — “socialized medicine” and “bureaucrats making decisions instead of physicians and patients” — as well as some new scare tactics: “death panels” and “euthanasia.” Ironically, we hear little about “justice” or “fairness” — core values of our society.

In 2000 we had an opportunity, but failed to act. Will we repeat that error in 2009? What happened to the “wisdom of the American people” and many of its political leaders?

Robert Knopp, a physician and medical educator, lives in St. Paul.

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Comments (5)

  1. Submitted by myles spicer on 09/15/2009 - 11:01 am.

    Cheers to a reasoned, rational, intelligent article from one who should know. Sadly, Dr. Knoop’s voice is outnumbered by a factor of about 50 million (dollars) to one in this lopsided debate between citizens and lobbyists.

  2. Submitted by dan buechler on 09/15/2009 - 02:07 pm.

    Your recount of the 52 year old victim was searing. Keep writing more, more often. Please.

  3. Submitted by Richard Schulze on 09/15/2009 - 10:43 pm.

    First, our system is so expensive and inefficient that we can’t afford it anymore. It’s a big competitive disadvantage for U.S. industry. Second, Americans are too decent and too generous to accept a system that leaves tens of millions of our fellow citizens without access to health care. That’s morally unacceptable.

    All over the world, health insurance is nonprofit except the U.S…. And as a matter of fact, when health insurance started in the U.S., the original Blue Cross and Blue Shields in every state were nonprofit, and they operated fine. The concept is more like the taxes you pay to operate the fire department in your town. Most people will never have a fire at their house, and therefore, the fire department makes enough money from everybody to put out the ones that do happen.

    Single payer systems have one goal in life, and that is to keep people healthy. That’s what they’re for, and the reason for that is those countries with single payer have all decided that there’s a basic conflict between making a profit for investors and covering people’s health.

    Our multi-tiered health care system, it’s really an expensive system to maintain because there’s so many different systems within it. There’s so many different forms of billing. There’s so many different prices. It’s just vastly simpler if there’s one set of rules and one set of forms and one price or one regional price for the whole country.

    You go to the doctor in France and that doctor, by law, is required to post on the wall the price she’s going to charge you for the hundred most common procedures that she does. And then the next column says how much insurance is going to pay you back. And the next column says how many days before the insurance pays you. No doctor in America could do that because they don’t know what they’re getting paid. They get 30 different fees for the same procedure in the same week because of all the different plans.

    The result is enormous administrative complexity. The American health insurance industry – you know, it’s free enterprise, it’s competitive, those guys, as we said, make huge salaries – it’s the least efficient payment system in the world. They spend 18 to 20 percent of every premium dollar on administration costs.

    Big Pharma is a whole other set of problems.

    Americans pay more for pills than people in any other country. Sometimes, the same tablet made in the same factory costs $1 in the U.S. and 20 cents in Britain. If we could negotiate lower prices in the U.S., the drug companies would then try to raise prices overseas to make up for the lost revenues.

    The pharmaceutical industry spends billions on research. Drug companies say they would have to reduce R&D if Americans paid less for their drugs, but the companies spend more on marketing than they do on research. In Switzerland, when the government started negotiating lower prices for drugs, the companies cut their marketing budgets and maintained the level of R&D.

    For profit health insurance and Big Pharma are the status quo

  4. Submitted by Steve Titterud on 09/16/2009 - 02:28 pm.

    Thank you for your voice, but as noted above, speaking common sense about our health care system is like peeing into a hurricane.

    I think this whole debate shows that significant political reform is necessary to achieve meaningful health care reform. Our political system is driven by the influence of money, not the national interest.

  5. Submitted by Richard Schulze on 09/16/2009 - 10:36 pm.

    Steve, How do we rationalize the very rational and logical approach to where we are confronting the problems in the healthcare system and how this country has traditionally and forever has made its decisions?

    Politics, money, influence and balancing different versions of the truth. Playing on peoples fears and all the other tricks and methods that are used to make large decisions like this.

    The costs of being misleading are very low in contemporary America. Damning with faint praise.

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