Final thoughts before the Oregon election

Since I started this blog, no issue has captured commentary as passionate and thoughtful as Oregon’s Measure 23 – On Oregon’s measure 23. I urge you to go back and read the original post and the subsequent comments.

Thanks to the many comments, I have focused on this issue. In the car returning from my golf trip, I discussed these issues with 2 good friends (not physicians). Several issues have crystallized as I have pondered this measure.

Our health care system is broken. While we provide the best specialty care in the world, we have too many holes in the safety net. Most Americans can get bypass surgery almost on demand, while others cannot afford their blood pressure medications. Thus, one must ask, whether the trade-off for excellence is a system of winners and losers.

Many would argue that this trade off defines capitalism, and why should medical care be any different. We rarely decry inequality in housing, transportation, clothing or food, why is medical care different? One could imagine that once one socializes medical care, one starts down a slippery slope.

We should, however, be able to afford a reasonable (defining reasonable may be impossible) base of care for all. Our current system makes that very difficult. However, would we accept the cure? Read Brian Gray’s comments written earlier today

My brother in law just died in England. He was 65. He has been waiting months for a quadruple by-pass operation. He rose to be number 10 on the waiting list then he died. My friend Tom Kennedy age 71 in England needed a hip replacement. Waiting time, 4 years. He flew to the USA and paid to have it done here. Waiting time One day. I lived for 36 years in Britain before moving to the USA and saw the abuse in the system there. Everyone feels they should go to the doctor for the slightest thing. Got a cold? Go to the doctor. Want time off work? Go to the doctor and tell him your back hurts. Britain has now introduced private medical insurance. There’s a clue. The Scandinavian countries are having an even worse time with their Government run health plans. Having lived with both systems I can say that the existing American model is light years ahead of the European welfare state. The proposed Oregan plan is far more extreme than the money losing European ones. Taxes will go through the roof. Treatment will be limited to save money. Doctors will leave the State, just as doctors and dentists leave Britain. Deductibles and co-payments control abuse of the system. How many people leave the USA and go to Britain or Cuba or Russia or Germany for medical treatment? NONE, but thousands of their citizens come to America in order to receive the best treatment in the world. There is no free lunch.

Please read that again. Our system works in its own way. We are the envy of the world. That does not mean that we could not improve our system.

I would like to see several improvements, but I do understand the political realities. We would need the Democrats to show courage against the trial lawyers and the Republicans to show courage against the large pharmaceutical firms and the HMOs. I doubt this will happen.

We need an intelligent system of ‘first contact’ care. I hesitate to use the term primary care because most readers will not read that phrase as I mean it. I consider primary care’s most important attributes as comprehensiveness and continuity. A good primary care physician works to aid the patient through the health care maze. This includes advising the patient on how to improve their health (diet, exercise, seat belts, immunizations, screening), evaluating for risk factors, and treating those risk factors. The good primary care physician can diagnose and treat most complaints, and when the patient needs referral, then pick the appropriate subspecialist. Many patients will then consult that primary care physician about the proposed plan of action (should the patient have an operation, or take chemotherapy).

Alas, my concept of primary care differs from the picture painted by too many subspecialists and by the insurance companies. My concept of primary care is not hurried, the patient and physician have time to spend together to plan an approach to health or an approach to treating either a risk factor or an illness. One cannot do that in 15 minutes. One cannot do that for $39 when the overhead costs $50.

Unfortunately, my concept of primary care is not accepted in most of the US or Canada or Europe. If we could support this concept, we would not have as many holes in the safety net. Supporting such a solution does not have enough flare for politicians. I fear that few understand the implications of such a solution. Most primary care physicians understand, but despair at even dreaming of that solution.

So where does that leave us with Measure 23? This measure has good intentions. We would like to provide health care to all. I wonder if our society will ever be willing to pay for that luxury. Measure 23 has major flaws, from the financing structure, to the naive assumptions. It should fail for those flaws. Hopefully, it will fail on a close vote, and the debate will continue. I only hope that those in favor approach the debate in a rational way. They must develop a better solution than Canada or England, because those systems are not worth emulating.

As I get back off my soapbox, I would like to thank all the commenters on this issue. You make important points which we should all consider seriously. As in many political issues, there are no right or wrong answers. Our challenge is to anticipate the unintended consequences. In this case, I believe those consequences would negatively impact health care in Oregon.