Unitarian Universalist Church of Palo Alto

Reflection: The Health Care Dilemma

Rita Hays
Sunday, April 6, 2008
Palo Alto, CA

Deciding how to pay for health care is not easy. The only thing that is certain is that our current system doesn’t work for everyone who should receive care. Options include a requirement that everyone carry insurance, a single payer system with uniform rules and enforcement, a system where everyone pays his or her own costs, a bifid, trifid or myriad system! None of these works perfectly.

I have seen a number of these systems. During my childhood, everyone paid. Insurance and HMOs may have existed elsewhere but were not a part of my world. Medicine was less complex and much less expensive. No one ever became bankrupt because of medical costs. Charity care was a part of a doctor’s ethos, and public hospitals did not expect indigent patients to pay. The poor may sometimes have received second-class care, but they did receive care, often good care.

Gradually, insurance became available to more and more working people, making it possible for them to get more reliable medical care when they needed it. And when Medicare came in, there was a remarkable change in the entire culture of access to care. At first, Medicare covered all costs for a person over age 65. Suddenly, standards were raised in doctors’ offices and in hospitals. With higher standards, costs went up. Now people under 65 had to get insurance to protect themselves from the risk of medical costs they could no longer meet. And, as we know, the Medicare program, as have other government-funded programs, later became less generous.

So now we have a system where, by and large, everyone gets first-class care, if they get it at all. The first thing that a clinic or office appointment clerk asks is “What is your insurance?” Health-delivery systems like emergency rooms, that are required to treat those without insurance, are under stress.

There are some attempts to change things. County-wide systems of clinics are present in San Mateo and Santa Clara Counties. The poor who learn about them and who can get to them receive limited care, largely from volunteer physicians. I volunteer in such a clinic in Redwood City. We do what we can for those who come, and that is a great deal. Local nonprofit hospitals provide free laboratory and radiology. Many prescription drugs are available to give to patients. However, the surgery available is limited to what a volunteer surgeon can do on site, a surgeon who brings his own instruments that he has personally had sterilized! When I sent a patient to the county hospital for a very simple procedure, she was told to bring $3000 to pay for it! Of course, she didn’t have the procedure.

I have experienced some hospitals in countries with socialized medicine or universal health insurance. They remind me a bit of our hospitals before Medicare came in. Patients wait a long time for procedures that are not emergent, and that means that one can’t repeat a study if it raises questions. The physical plants aren’t so shiny. There is less use of disposables. In England, and perhaps elsewhere, this has now led to a 2-tier system a bit like we had here before Medicare, with those who choose buying insurance or paying out-of-pocket, the others accepting the system available to all. But at least everyone has access to the universal system, a better situation than is true in our country.

Insurance companies are, of course, businesses. They prefer to avoid situations that will cost them a lot of money. They markedly limit their coverage of psychiatric illnesses. They often refuse to cover pre-existing conditions. They sometimes refuse to cover procedures such as transplants. Looking at them as businesses, especially at their generous executive pay, we may exaggerate their greediness when we consider these restrictions. Those same high cost items will also be there under any system we devise.

One such item is kidney dialysis treatment. When it first came in, there was widespread discussion of rationing it because of its cost. At first no one over age 65 could receive it. This problem got the attention of Congress, and now dialysis is available to anyone who needs it under a special law.

Mental illness is at the other end of the spectrum. The numbers of patients and the difficulty and chronicity of their treatment could swamp an insurance system. So arbitrary limits are placed, and many psychiatrists won’t even deal with insurance companies or Medicare. The result is that many in need are left without care.

When my daughter had her acute schizophrenic break, I was desperate for a cure. I had access to many advisors, but tended to listen to those who offered the most hope. I paid for far more care than my insurance would cover, depleting my finances to the verge of bankruptcy. No cure occurred. However, during that period of intensive treatment she was able to go back to college, graduate with honors and get a job with an excellent company. Eventually, she relapsed and she is no longer able to work. But at least she had a few good years. Was it worth it? Even in retrospect, realizing that my hope for a cure was unrealistic and what it cost, I don’t regret trying.

Others faced with dread diseases have the same choices. If the possibility of a cure, or even of a remission, is offered, they want to go with it. Charlatans thrive on this. Experimental treatments occasionally cure where standard treatments cannot. But are we as taxpayers to pay for them? Perhaps, in some cases, but it may take Solomon’s wisdom to decide.

If we are to have a realistic health care system that benefits all our citizens, we must focus first on prevention of disease. The current focus on children is the right place to start. Education about diet and exercise, and providing the right venues to follow-up on that education, would go a long way toward a healthier population of all ages. For treatment of disease, we do need to think about what is most cost-effective, but within limits. Those unfortunate enough to have an expensive disease must somehow be accommodated also. We must be aware of the true costs of the decisions we make.

 

Sermon: Health Care for All — A Matter of Faith? by Suzanne M. Marsh