Not Far Enough?

David Mealiea '15
uvmmedicine blogger David Mealiea ’15

This opinion piece by Gabriel Edwards and David Mealiea ’15 first appeared in The New Physician. See the article.

In medical school, we are taught that practicing good medicine means first asking a good history. Gathering relevant information guides the review of the patient’s body systems, physical examination, and ultimately the assessment and plan that leads to an effective medical intervention. With experience, the doctor learns to recognize patterns which help guide clinical judgment. We are at the beginning of this process, but some patterns have already begun to emerge.

There’s the 40-year-old woman who can’t afford the premiums and deductibles on the insurance offered through her workplace. She suffers from depression and has to take the generic form of her preferred antidepressant, with significant psychiatric side-effects. There’s the 58-year-old man with musculoskeletal issues. The attending physician acknowledged that his workup and treatment would be different had he been insured. He might otherwise have received an MRI of his back and treatment of his right leg problems, correcting his posture. Then there’s the 27-year-old who can’t afford insurance covering the suboxone treatment for his opiate addiction, forcing him to buy it on the street.

The Patient Protection and Affordable Care Act (ACA) was signed into law by President Barack Obama on March 23, 2010, with the goal of reducing the number of uninsured Americans by making health care more affordable to Americans. It achieves this through mandates, subsidies and insurance exchanges. But a May 14, 2013, report by the Congressional Budget Office projected that the number of American who will remain uninsured in 2023 will be 31 million, revised upward from a previous projection of 30 million.

The patients we described above are just a few of those millions of Americans struggling with the effects of being uninsured. But additionally, we have an epidemic of inadequate coverage among Americans who are insured. Without solving the latter, we won’t adequately help the former even if we managed to insure every man, woman and child in the country. Getting everyone on board with health insurance is an initial step, but if everyone is on board a vessel which is slowly sinking, we haven’t gone far enough. In theory, paying for insurance should result in adequate, affordable health care. In reality, it doesn’t. And that brings our entire approach to financing health care into question.

Massachusetts implemented a policy of universal health coverage in 2006, four years prior to the ACA’s passage. A study published in the American Journal of Medicine showed that the amount of bankruptcies in the state due to illness and medical bills were reduced, but not significantly: dropping 59 percent to 52 percent from 2007 to 2009. Furthermore, the study states that “in 2009, 89 percent of debtors had health insurance at the time of filing.” It seems antithetical to us that the provision of health care necessary to ensure an adequate quality of life should result in financial ruin. Medicine is complicated enough without having to consider whether even the insured patients can afford the care they need to live healthy, productive lives.

The insurance exchanges offer plans of various cost, and the most expensive plan, dubbed “Platinum,” will pay 90 percent of essential health benefits. It is the responsibility of the patient to pay the other 10 percent of health care expenditures out-of-pocket, in addition to added costs associated with care received by providers deemed out of network. A June 2013 study published in the journal Health Services Research found that among those who pay for out-of-network services, 58 percent of inpatient services and 13 percent of outpatient services were paid involuntarily. An individual navigating our highly fragmented system will pay for the health care most immediately available to them in times of need, in or out of network. This demonstrates a pitfall of a system that expects individuals to make rational economic choices when purchasing health care in situations that are often medical emergencies.

We believe that health care reform has to go beyond tethering more Americans to our current, dysfunctional system. But the only way that we can evolve toward a better system is to transcend the scope of the current debate that has dominated mainstream discussion. One of the effects of the battle to pass, preserve and implement the ACA has been the way it has framed this debate as a simple dichotomy between the law’s articulated vision and the status quo.

We write this article to encourage fellow students to consider another way, one that imagines a system that can serve all Americans’ needs. We have seen the financial and human costs that have resulted from our current system. Whether we choose to acknowledge it or not, the suffering of those without adequate access to health care weighs on us all, economically and spiritually. Reform should strive to bring people together in the task of improving the well-being of all Americans and not, as Dr. Margaret Flowers said in an opinion piece in Al Jazeera, to lower “the bar for what is considered to be adequate health insurance coverage.”

Our national conversation has been dominated by the question of insurance, and as such as we have one of our own: shouldn’t the purpose of insurance be to create a pool as wide as possible so that those of us who are sick can benefit from the support of those of us who are well? Other industrialized nations have managed this; here in the United States, Medicare and the Veterans Administration have managed the same for subsets of our own population, and are popular and operate with minimal administrative cost when compared to private insurance companies. Why wouldn’t a single unified system, then, encompassing all Americans, most effectively accomplish this? One simple enough not to crumble under the weight of its own complexity and in the face of an opposition that would rather profit from the fragmented status quo?

Ultimately, we want to start a conversation not just about health insurance, but also health care. We believe that ensuring health care for all isn’t just a luxury, sacrificed to the demands of what popular debate current frames as “realistic.” It is an economic and moral necessity. We want a system where future medical students won’t have to see as many of the things we’ve already seen in our young careers: namely, patients suffering due to the multiple barriers they’ve had to surmount simply to access the care that they need. Ensuring access to adequate care for all Americans is a litmus test of the health of our democracy, and it will require embracing the unavoidable reality that we are in this together.

What are your thoughts about this topic?