Unitarian Universalist Church of Palo Alto

Reflection: Health Care for All

Rita Hays
Sunday, November 23, 2008
Palo Alto, CA

When I was in medical training, there was health care for everyone in this country. That doesn’t mean that here was good health care for the poor, but the public system at least gave the poor a refuge when they were sick. There were private hospitals, where everyone paid, and public hospitals which were free. There were hospitals for the mentally ill, which were also free. I remember visiting a special hospital for children with congenital abnormalities such as Down’s Syndrome, also free. In teaching hospitals, there were private patients and house patients. The house patients paid modestly, and were cared for by trainees who were supervised to varying degrees.

The free care in the public hospitals was far from ideal. I remember the Los Angeles County Hospital as a dirty, overcrowded building filled with interesting patients. The staff were much too busy. A young doctor would be swamped with problems and might have time to cope only superficially. There was no time to think deeply about what the underlying problem might be, or to learn about social factors compounding the patient’s problems.

Then Medicare and Medicaid came along. Each patient old enough or poor enough to qualify for these programs became a private patient. The whole system was upgraded. Public hospitals started to charge for their services, and with the increased revenue they upgraded their facilities. Today’s County Hospital is shiny clean and well staffed.

The antipsychotic drugs made it possible for many people who suffered from psychoses to function out of the protection of a hospital, so there was less need for free public mental hospitals. Closing them saved the taxpayer a lot of money, and they were closed. They may have been far from ideal, but they were a refuge. Now, people with uncontrolled psychoses are likely to be street people.

With time, the public money for Medicare and Medicaid became insufficient to meet all of the costs of medical care, so private insurers offered “Medigap” policies to supplement what they offered Ð for those who could afford to buy the policy.

What is available now to the person with no health insurance who becomes sick? In this area, there are a few free clinics staffed by volunteer physicians. I work in one of them one afternoon a week. The care we offer is limited. What we do is high quality, but if the need is beyond our capacity there is no recourse unless the patient can pay.

More often such a person will go to an emergency room of a public or not-for-profit hospital. The ER has become the primary physician for many. If they must be hospitalized, they will be hospitalized. The difference from the old system is that now they are charged at the going rate for all of their care. If they can’t pay, they become debtors, and may owe, and be dunned for, hundreds of thousands of dollars. In effect, that will prevent their ever recovering from poverty.

So we are back to a two class system of health care, a bit different from that before Medicare and affecting different people in different ways. Those of us with a good health insurance policy have access to medical services that we would not have dreamed of in my youth. But the free public services available when I was in my medical training have disappeared, and a significant portion of our population has no access to health care. Emergency rooms are hampered by the need to provide primary care to the poor, making it harder for them to treat true emergencies.

What to do about it? There are some difficult choices to be made. Unless we spend even more in the medical sector than now, upgrading care for some may well mean downgrading care for others, including many of us. Yes, the fat cats could lose a little weight. Pharmaceutical company executives could live on smaller bonuses Ð but how much would that really help? A few medical specialists have exorbitant incomes, and their example is motivating some of the young to enter lucrative specialties. On the other hand, many primary care doctors, the family physicians, general internists and pediatricians, have already seen a drop in income as insurance reimbursements shrink. It shouldn’t surprise us that fewer medical students want to go into primary care, where the hours are long, the demand high and the income shrinking.

Our soaring national debt and the cost of our nation’s belligerency makes it unrealistic to expect much more help from the government (tax dollars) to right the unevenness in American health care access. If the poor among us are to have decent access to health care, the rest of us must accept sacrifices of some type or many types. Defining what those sacrifices must be is a tremendous challenge for our leaders and for ourselves.