'Yes we can' changeour minds about reform

January 1, 2009
Eric Trefelner, MD

Diagnostic Imaging, Diagnostic Imaging Vol 31 No 1, Volume 31, Issue 1

"Arrrgh!! Two hours onthis motor vehicle accidentcase with CTs ofthe head, face, chest, abdomen,pelvis, lower extremities, andcervical, thoracic, and lumbarspine for numerous injuries, andnow I find out the patient hasno insurance. He'll be in theICU-studied every day-formonths, and we won't get acent."

"Arrrgh!! Two hours on this motor vehicle accident case with CTs of the head, face, chest, abdomen, pelvis, lower extremities, and cervical, thoracic, and lumbar spine for numerous injuries, and now I find out the patient has no insurance. He'll be in the ICU-studied every day-for months, and we won't get a cent."

"Did you see last month's collections? The uninsured rate went from 30% to 40%. We are losing millions because of these people. They should go to the county hospital."

"Uhh! Now they're sending a total body scan on his wife. This'll be another two hours wasted and $6000 lost." "I'm getting a total kid scan on my workstation. What are names of those two you're looking at?"

"John and Barbara White."

"It's their kid. We are totally screwed. They'll scan everyone in the car, whether they need it or not. The ER should do only what is absolutely necessary on these uninsureds."

"Barbara White? Isn't she that nice woman who works part-time in admissions?"

"Yeah, but she was laid off last month. Such a wonderful person. Three kids."

"This is so sad."

"I know. That means there are probably two other kids in that car we'll have to read without being paid. We are going to lose thousands. I'm sad, too."

"Sixty hospitals in California have closed their ERs just to avoid having to take uninsured patients. Admin should close ours."

"Absolutely."

I have an embarrassing confession to make. No, not about my liking Simon Cowell on "American Idol." I used to work in a hospital where more than a third of our patients had no insurance, and all that work would go unpaid. Yet I could still be sued for malpractice- while doing work for free! Neither seemed particularly fair to me. What other private business in the U.S. is forced to provide free services to anyone who wants them?

Just try that at Nordstrom, Wal-Mart, or McDonald's, and you'll become intimate friends with their security personnel.

I have another confession. I don't like Hillary Clinton. I think this goes back to 1993, when she was trying to force universal healthcare on everyone. I thought it would be bad for the practice of medicine and, yes, my income. My perception of universal healthcare was medical care delivered with the efficiency, quality, and caring offered by your local DMV office combined with a fee schedule tied to a lowest bidder mentality. I was influenced by all the negative propaganda that flooded the airwaves at the time against Hillary's proposals, which was paid for, of course, by insurance executives who were afraid their incomes and personal fiefdoms would be adversely affected. Dr. William McGuire, the CEO of United Healthcare who made $125 million a year and $1.6 billion in stock options, comes to mind.

My opinion changed with an article in the October issue of Archives of Surgery, "Race and insurance status as risk factors for trauma mortality." This study demonstrated that an uninsured trauma victim, when compared with a victim of the same sex, age, and severity of injury, is 50% more likely to die than one who is insured. If you are black and uninsured, you are 78% more likely to die than an insured white person, while for Hispanics the figure was 130%.

There are a variety of reasons why this may be, but the most disturbing possibility is that patients who don't have insurance are not treated the same way even in the hospital, which may be the result of bias. This just seems wrong. Also wrong: A woman diagnosed with breast cancer who loses her insurance can never get coverage for the necessary chemotherapy from a new insurer due to the cancer being a "preexisting condition." The same often applies to children and adults with diabetes, asthma, or any chronic medical problem.

In 1993, our healthcare system was in trouble. Here we are 15 years later, and the trouble is worse and will cost more to fix. In 2007, we spent $7439 per person on healthcare, or almost 16% of gross domestic product. That's the highest per-person expenditure in the world, and yet we rank 37 out of 191 countries in overall health performance (right after Costa Rica-but before Slovenia!), according to the World Health Organization, and 72nd in overall level of health. (It's not surprising that the results engendered severe criticism of WHO.) We rank only 46 for life expectancy in the CIA World Factbook. The Scandinavian countries spend about $2500 per person per year and rank near the top of the list. Just reaching the level of care in the U.K. and France would save 75,000 to 100,000 lives a year.

Since 2001, healthcare insurance premiums have gone up 78%, while inflation has risen only 17%. By the peak of this recession, as many as 50 million people may have no medical insurance, up from 46 million now. That figure includes more than 10 million children. And these numbers do not include the even larger pool of the underinsured. Before the current recession, medical expenses accounted for over 50% of all personal bankruptcies, which increased 2200% between 1981 and 2001.

A Harvard study published in the August 2003 issue of The New England Journal of Medicine found that 31% of private insurance premiums go for administrative costs. Meanwhile, administrative costs for Medicare are only 3%. The Government Accountability Office and the Congressional Budget Office, in separate studies done in 1991, both determined that the administrative savings alone of a national health insurance plan could pay to cover all the uninsured people in this country. Current estimates are that such a plan could save at least $300 billion to $350 billion in administrative costs.

A single-payer model always seemed scary to me, conjuring visions of depressing waiting rooms with long lines and communal enema bags. However, I spent several weeks in Europe this year and spoke to individuals in Norway, Sweden, Denmark, Finland, and Germany about their healthcare systems. People were quite happy, and the statistics prove it. The U.K. has a traditional socialized medicine model and still outperforms the U.S. Denmark, Norway, and Sweden have a national health insurance system that is publicly administered but still has private as well as public doctors and hospitals. France, which WHO ranked number one in the world, and Germany both have multipayer models that are nonprofit and cover everyone. And yet most doctors and hospitals are private.

It is not surprising, then, that Massachusetts has legislated a universal healthcare program and that California, Hawaii, Maine, Connecticut, and Vermont are considering it. We have experienced a historic election and now have an African American president who wants to insure most of us. Hillary still scares me, but that is my own fault. I'm willing to take the next historic step and embrace Hillary's plan for universal healthcare- though not without malpractice reform.

Don't get me wrong, I don't trust any politician, and I am confident that Congress will make a mess of it all, but at least it would be a beginning. Healthcare may not be a right, but it is a necessity-and at least radiologists would get paid. Who knows? If the economy gets much worse, any of us could lose our jobs. But at least we outrank Slovenia!