One Pediatrician’s Perspective on Universal Healthcare

by Dan Summers

I share E.D.’s  skepticism about the private insurance industry, and wanted to chime in a few thoughts from a provider’s perspective.  Though the American Medical Association has decided to dig in its heels about government-sponsored health insurance, the Times is correct that the AMA does not speak for all doctors.

The practice where I am a pediatrician is owned by the local hospital where I live in northern New England.  Our patient base is a wide mix of the uninsured, those who have Medicaid, and those who are privately insured.  The surrounding communities have faced steadily-increasing economic stress as much of the local industry has been shuttered, and while the recent downturn in the national economy has not helped much, the area was already distressed before it hit.  I was in favor of government-sponsored health insurance before I arrived, and my work here has cemented by support.

Whenever the issue of government-sponsored health insurance (or “universal health care,” “socialized medicine,” etc.) is raised, the specter of “rationing” appears sooner or later.  Its mention is obviously meant to call forth images of bread lines and long delays in care in an effort to dampen public enthusiasm.  What nobody ever talks about, though, is that rationing already exists.  We just don’t call it that.

The first and most obvious example is that of the uninsured, who essentially self-ration.  Uninsured people still need health care; they just have to pay for it out of pocket when the need arises.  The stereotype is that they clog up our emergency rooms when they get sick, but recent reports and studies indicate that they are less likely to get emergency care (even when they really need it) because the know they can’t afford it, and unlike the insured they can expect a bill for the entire expense.  (Full disclosure – the author of the study interviewed for the Newsweek article is a friend of mine.)  When uninsured patients show up for care in my office (where they are seen just like anyone else), referrals and treatments are often rendered unavailable because there is just no way that they will be able to pay for it.

Of course, some uninsured patients access care that they simply cannot afford.  Accounts go into collection, and sometimes patients are forced into bankruptcy due to medical expenses.  Most of the time, however, the hospital or practice simply eats the cost, which is eventually passed along to everyone else in the form of higher fees and premiums.  On the provider side of things, there is a gentle background thrum behind all that we do, encouraging us to “maximize efficiency” or some similar euphemism.  This tends to mean seeing as many patients as will fit, and billing punctiliously (but, I hasten to add, always honestly) to get the highest fee possible, in an effort to squeeze us like the proverbial turnips and hope that we bleed black ink.

The story is different for Medicaid patients, of course.  Payment for services isn’t an issue.  However, many providers (particularly specialists and dentists) simply won’t see them, full stop.  While this would seem to be an argument against public health insurance, it could be reasonably assumed that if a government-sponsored plan were made available to the general public and carriers comprised more of the patient population, there would be more of an incentive for providers to accept it.  As it is, Medicaid patients simply must endure working their way down months-long waiting lists.  Apparently we are willing to accept rationing (which, again, this clearly is), so long as only the poor are expected to endure it.

The insured are often discussed as though they are a homogenous whole, while in reality insurance plans are quite varied in coverage and quality.  While I don’t have numbers to back up this impression, one thing we seem to have noticed in our office is that people are responding to mounting financial pressure by switching from more comprehensive (and expensive) plans to high-deductible plans with cheaper premiums.  Though in theory they are “insured,” in practice their out-of-pocket costs are such that they seem to behave more like people with no insurance.  Our triage nurse is fielding more calls from people requesting management over the phone, which in many cases is fine.  (There’s no reason to come in just for me to confirm that yes, in fact, your daughter has a cold.)  On the other hand, there are some things that just can’t be managed without seeing the patient first, and there has been a notable uptick in the number of patients evincing reluctance to come it because they don’t want to shoulder the co-pay.

Even patients with “comprehensive” coverage have their care rationed.  It’s just dictated by a profit motive, rather than a government agency.  Private carriers routinely have to be contacted by office staff (some of whom have no other duties) to get approval for referrals, tests and treatments.  Sometimes they pay, sometimes they don’t.  Even services that are ostensibly in-network or “covered” can yield a very surprising billing statement, and we not infrequently get calls complaining that something we have ordered or done wasn’t covered by someone’s insurance.  Since every carrier and plan is different, we have no way of knowing what costs our patients are going to shoulder when we formulate a care plan.  While I tend toward a “therapeutic/diagnostic nihilism” in my approach (in that I prefer not to order tests or treatments unless there is a compelling reason to do so), sometimes those tests or treatments are indicated, and having insurance really doesn’t guarantee that they will be paid for.

Geographic constraints on healthcare access could arguably be considered another form of “rationing,” but I don’t want to lose track of my point by trying to cover too much territory.  While I will readily concede that any public-insurance plan will have its downsides and drawbacks, I am unbothered by the idea that “rationing” will be one of them.  I already know what rationing looks like, because I’ve been dealing with it for years.