Saturday, January 30, 2010

I'm sick of the politics. Patients need health care reform.

At this point it seems like everyone’s frustrated with health care reform. Liberals feel betrayed about the public option and worry that we’ll see little actual “reform.” Conservatives are skeptical about the proposals’ ability to control costs, and worry that expanding public programs without stronger cost controls will leave our country further in debt. Having debated compromises, and compromises of those compromises, many of us are left wondering whether health care reform even matters anymore. Well, as an American, I am disappointed in the broken political process; as a progressive, I worry my core values of justice and equity are being undermined; but as a doctor, I cannot give up on reform.

More than a year ago, Mr. Nelson*, a hypertensive man in his 50’s with two grown daughters and a college bound son, came in as a new patient. He had lost his job as a salesman and with it his health insurance. For awhile, he paid out of pocket for the medication prescribed by his previous doctor, but he could no longer afford them. The community health center where I work offers sliding scale payment and low cost medications, so when he began having severe headaches, he came in to see if we could help. His blood pressure was sky high and I was concerned that he could have a stroke, but he did not want to go to the emergency room fearing the costs. Instead, I wrote a few prescriptions, saw him several times over the next few months, and we finally got his blood pressure under control.

I saw Mr. Nelson again a few weeks back, and he has still been unable to find work. His wife’s employer does not offer health insurance, and with her salary and his unemployment benefits, their income is too high for Medicaid. He could purchase coverage on the non-group market if it was affordable, but he has looked and this is not an option. Over the past year, I have been worried about his daytime fatigue and snoring, and I suspect he has obstructive sleep apnea. However, he cannot afford the thousands of dollars for a sleep study and respiratory equipment, so he must delay this medical care. It is a gap that the health center cannot fill. Each visit he is upbeat about his family and his blood pressure, but I cannot help but worry that sleep apnea is causing permanent damage to his heart and lungs.

I have other patients like Mr. Nelson, and I’m sure there are many other Americans out there as well, who are just getting by, and maybe cutting their pills in half to make them last, and delaying medical care as they focus on more pressing matters like putting their kids through school. The health care horror stories are heart breaking, but thinking about my patients on the verge of a bad outcome or one illness away from bankruptcy, I feel impassioned to demand reform now. We cannot wait for the perfect plan. A health insurance exchange with subsidies for private insurance is not the same as a public health insurance option, but it would offer affordable coverage to Mr. Nelson. If 45,000 preventable deaths annually are attributable to lack of health insurance, the Senate bill, which covers 2/3 of the uninsured with subsidized private insurance and expanded Medicaid, could potentially save 30,000 lives. If this is not the purpose of health insurance reform, I’m not sure what is.

Many are calling for the House to pass the Senate bill, and fix issues like the level of premium subsidy via reconciliation. This won’t remake the American health care system into a model of efficiency and equitability, but it does move us from debate to action. It will help 30 million Americans who are uninsured. It will provide security to those with private insurance. It will strengthen primary care, prevention, and wellness. Waiting any longer is just not an option.

*I thank Mr. Nelson for allowing me to share his story. I have changed his name and other minor details in order to protect his privacy.

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