Income plays a major role in determining the quality of health care people get, attests a doctor who volunteers annually in the Mississippi Delta.
Every summer I volunteer in the Tutwiler Clinic in the Mississippi Delta, one of the poorest areas in the country. For the Catholic nuns who operate the clinic, treatment never depends on payment; the nuns make ends meet through Medicare, Medicaid, the occasional insurance reimbursement, and charity. The quality of care is extraordinarily high by any standard, yet here the inequities of our health care system are dramatic. The starkest example of these inequities is the fact that many of my patients at the clinic simply have no expectation of being healthy as adults. They are poor and historically have not had access to qualified, caring doctors.
One Monday morning I arrived to find a muscular, middle-aged man waiting outside the clinic door, holding his ear and in obvious pain. He said he just wanted ear drops because he had to get to work or he’d lose a day’s pay. When I examined his ear it was apparent he had a severe infection in his ear canal and outer ear. This condition is rarely seen in healthy people, but is a clear sign of uncontrolled diabetes. His blood sugar was five times normal, and it would have to be controlled before his ear infection would even respond to antibiotics. His blood pressure was sky high and he had a fever.
I explained all of this to him and urged him to go to the hospital in Clarksdale for immediate hospitalization. He looked at me as if I had two heads. “Sorry, Ma’am, but I just want drops for the ear and I’ll go back to work. My boss is going to be angry because I’m late right now.” Over the past few months he had lost about ten pounds and was constantly thirsty, two common signs of diabetes. He had attributed his weight loss and thirstiness to hard farm work in the hot Mississippi sun. He hadn’t seen a doctor in years and had no idea that he had dangerously high blood pressure and diabetes. Although he had worked on the same plantation for twenty years and was now a foreman, he had neither health insurance nor an allowance for sick time. As to my suggestion of going to the hospital in Clarksdale, he flatly refused to consider it.
Over the next few hours at the clinic we gave him intravenous fluids and insulin to start bringing down his blood sugar for the ear infection. He agreed to come back twice a day, before and after work, to get insulin and IV antibiotics and to learn how to treat his diabetes and high blood pressure.
By the end of the week he looked much better. The clinic had provided all of his medicines and his treatment free. I’m sure that if his unbearably painful ear had not forced him to come to the clinic he would have collapsed working in the fields, another casualty of our inadequate health care system. It is estimated that at least 22,000 (and possibly more than 100,000) people die in the United States each year because they do not have health insurance and access to care.
This small clinic can serve only a tiny fraction of the residents of the Delta, most of whom are in desperate need of medical attention. But it offers a vision of the high-quality medical care that could be delivered to all residents of the United States if a single-payer health program were adopted, one that guarantees access to highly skilled clinicians without charge.
What are the essential elements that are necessary for high-quality health care, and how would a national health care system achieve this?
ACCESS
Quality of health care has little meaning if millions are unable to access care in the first place. We all need to be able to see a doctor when we are sick, so guaranteed and automatic health care coverage from birth to death is a must. This coverage must include not only care for illnesses and injuries but also preventive care, mental health care, medications, dental care, and long-term care.
This concept of access to health care is so important that in 2008 the American Cancer Society committed its entire $15 million advertising budget to promoting universal health care. Its chief executive, John R. Seffrin, said, “If we don’t fix the health care system, that lack of access will be a bigger cancer killer than tobacco. The ultimate control of cancer is as much a public policy issue as it is a medical and scientific issue.”
Those diagnosed with colon cancer who are uninsured have a 70 percent greater chance of dying within three years. Uninsured women diagnosed with breast cancer suffer an almost 50 percent higher risk of premature death. Halfway measures such as free screening for cancer offer little comfort to the uninsured or under-insured who realize that they will not be able to afford the high cost of treatment.
A SINGLE STANDARD OF EXCELLENT CARE
Whom would you point to who does not deserve equal high-quality care? The only way to create an equal opportunity to get high-quality health care is to have a single, comprehensive health care plan for all. This means no bare-bones plans whose high deductibles and co-pays effectively exclude us from health care. If the health care system treats all of us equally, then the most powerful among us will make sure that this is a top-notch system.
Our current system compromises the health care of all of us, insured and uninsured alike. Take the example of the severe overcrowding in hospital emergency rooms. Half of U.S. emergency rooms report daily overcrowding, with that number climbing to two-thirds of urban emergency rooms. This can result in vital delays in treatment, while overworked staff struggle to handle all of the patients. More than half a million ambulances are diverted to less crowded emergency rooms each year in the United States, delaying lifesaving care for the critically ill.
In many areas of the country, specially staffed and equipped trauma centers have closed because they are not profitable, forcing patients to lose those initial critical minutes of care that are so often vital in saving lives. Three-quarters of hospitals have difficulty finding specialists to take emergency or trauma calls. And despite all the rhetoric about preparedness, our overcrowded and underfunded emergency care system is ill prepared to respond to a major disaster—be it a natural one, a disease outbreak, or a terrorist attack.
CHOICE AND QUALITY OF CARE
We need to have free choice of doctors and hospitals, without being restricted by a managed-care plan or a constantly changing list of in-network providers—or being denied nonemergency care entirely for being uninsured. It is ironic that opponents of national health care cite their fears that Americans would lose freedom of choice under a national plan. Exactly the opposite would be true. With universal access and comprehensive coverage, free choice would be guaranteed. Closely related to this is the need for continuity of care, or what is sometimes referred to as a medical home, where a team of health care professionals including doctors, nurse-practitioners, and nurses knows us and our medical problems, takes care of us appropriately and efficiently, and advocates for the best medical care without any financial conflict of interest. Our care could also be coordinated when we see specialists or are hospitalized, and the number of medical errors caused by poor communication would be reduced.
The quality of health care and the outcome of different treatments must be measured and monitored so we can constantly fine tune and improve health care. But that is impossible in our current private system. The for-profit health insurance companies don’t study the health or health outcomes of their clients in order to improve their services. Far from it. They monitor those who are sick and expensive to care for and try to exclude or drop them from their plans. In fact, it may surprise you to learn that almost all of the population data we have on the effectiveness of different medical treatments and outcomes come from our government-sponsored public health care programs—Medicare, Medicaid, and the Veterans Administration system.
Under a unified single-payer health care system there would be far greater accountability because we would have medical treatment and health outcomes data for everyone and we could better study and determine effective medical practice. We could monitor physician competency on a nationwide basis and identify the outliers providing poor care.
We rely on the competency of our doctors, but our current fragmented system renders it impossible to track a doctor’s performance at an accepted medical standard. A good electronic medical record system could improve a doctor’s practice through reminders for recommended screening (like Pap smears, mammograms, and cholesterol checks), guidelines for chronic-disease management, and alerts for drug interactions or improper doses of drugs. It could also detect practitioners who are far off the mark for appropriate medical care, something our current system has failed at miserably.
ELECTRONIC MEDICAL RECORDS
There is no doubt in anyone’s mind—whether they be in big business, the medical establishment, or the highest levels of government—that a unified secure electronic medical records system must be created. Indeed, every major Democratic presidential candidate has made an electronic medical records system a cornerstone of his or her health care reform package. However, the overarching question is whether such a program can be realized without a single-payer health care delivery system. Already Microsoft, Google, and Texas Instruments have launched or are about to launch competing electronic medical records systems. It is obvious and predictable that a multiplicity of electronic medical records delivery systems will evolve and the important characteristics of the Veterans Administration’s medical records system—unified, affordable, and readily available—will disappear.
What we need is a system that scrupulously guards our medical privacy and confidentiality while affording health care professionals immediate access to a patient’s medical history. Consider the case of a veteran who receives regular treatment at a veterans’ hospital in New York. If the veteran were to suffer a heart attack or a life-threatening emergency while visiting relatives in Southern California, that vet could enter the nearest veterans’ hospital, whose medical staff could have access to this vet’s entire medical history within seconds, allowing them to proceed to the most informed course of treatment. The veterans’ hospital system has in place a unified electronic medical records system that links all of its hospitals. This was invaluable after Hurricane Katrina, when thousands of veterans from New Orleans and surrounding areas sought health care at Veterans Administration facilities throughout the country. Nothing comparable would be possible in our present diffuse and fragmented health care system.
From a public-health standpoint, such a unified computerized database would permit early detection of epidemics like a severe flu season and allow prompt immunization to better control it. It would allow careful tracking of the incidence of cancer, heart disease, and depression so we could better study these chronic illnesses and allocate resources appropriately.
We need to combine the information from an electronic national database with strategic thinking to improve our systems for delivering health care more efficiently and cost effectively, while always having quality as our primary goal.
HEALTH PLANNING
Among the many benefits that would flow naturally from eliminating for-profit health-insurance companies and financial conflicts of interest would be a clear assessment and allocation of resources—to eliminate expensive redundancy of hospital and radiology facilities and to regionalize specialty surgery in accord with the knowledge that hospitals with a high volume of surgery have better proficiency and patient outcomes than hospitals with low volume. More focus could also be given to preventive health care.
PATIENT-PHYSICIAN RELATIONSHIP
At the heart of excellent health care is a patient’s trusting and ongoing relationship with a personal primary-care physician. A recent international study by the Commonwealth Fund showed that having a “medical home,” where you have a regular doctor who knows your medical history, is easy to reach by phone during business hours, and will coordinate your care with other physicians or hospitals, is associated with more comprehensive and cost-effective care as well as greater patient satisfaction.
Clinicians need to have the time to listen carefully and respectfully to a patient’s problems to determine appropriate, cost-effective treatment. The pressure on doctors to see patients in ten- to fifteen-minute appointments ultimately saves neither time nor money and leads to increasing frustration and medical errors.
A number of years ago I saw an elderly woman in a neighborhood clinic who had no regular doctor but had seen several different doctors over the past year, each of whom had added new and more potent medicines in order to control her blood pressure. She had lots of side effects from these medications, but her blood pressure remained dangerously high. She assured me that she took all of her medicines religiously and she denied adding any salt to her food. I asked her to describe in detail her actual meals: for breakfast, bacon and eggs; for lunch, canned soup; and for dinner, canned beans and rice. It turned out that she was getting a huge amount of salt in her diet that overwhelmed her medicines. She agreed to try to eliminate canned foods, and over several weeks her blood pressure was easily controlled with only two medications.
By my taking some extra time to explore her diet and then to educate her to the danger of ingesting large volumes of salt through prepared foods and to explain how her medicines operated in lowering her blood pressure, she was able to understand her high blood pressure and to take an active role in controlling it. If physicians are compelled to treat their patients at an assembly-line rate, too many subtle or complicated diseases will go unnoticed. Only a system dedicated to the optimal care of the patient—versus the optimum profits of insurance companies—will afford doctors the time that is needed to explore and diagnose thoroughly and competently. A single-payer system is the moral and economic answer to our current health care crisis.
Adapted from 10 Excellent Reasons for National Health Care.