We were all seated around the table. Everyone had been brought up to date as to what was new with everyone else,
the dinner orders had been taken, and bread and butter were being passed around. As the conversation turned to
politics and current events, the dreaded question came: "Tony, you're a doctor, what do you think about this
health care reform issue?"
The discomfort I felt at being asked the question derived from two sources. Number one, I am a physician,
health care is my life, and it is reasonable to expect that I would have some well thought out, insightful,
and firm opinions on the topic. The second was that, in fact, I did not feel very knowledgeable nor had I
formed any clear opinions about the specific reforms of health care that were being proposed.
I guess it is somewhat amazing that I don't feel very knowledgeable or have strong opinions about legislat
ion that could have such a profound effect upon my professional life. Sure, I always read Jack Lewin's "Da Blog" (1)
with great interest, but I can't say that I know the specifics or appreciate all of the implications of what is
being discussed. However, my embarrassment is buffered by the fact that none of my colleagues seem much more
engaged than I am. It is rare that I encounter any serious discussion of health care reform at the hospital,
either in clinical settings, conferences, or the cafeteria. My colleagues seem equally strangely disengaged
from the debate that is going on regarding the field in which they work. It may be that we are all resigned
to the fact that what will happen, will happen. However, I have the impression that a greater influence is
the sense that our role is to deliver the best care possible to those who need it, regardless of government
policies. We are more concerned with defining best care and how we can advance it rather than the nuances
of insurance coverage. In this regard, I suspect that we generally have our priorities in the right order.
There seems to be general agreement that major changes in the health care system are needed. I fully agree
with the necessity to rectify some suboptimal aspects of the health care system. There continues to be an
inexorable increase in spending for medical expenses, and the Centers for Medicare & Medicaid Services
estimate that, at the current rate of growth, the health share of the gross domestic product will exceed
20% by the year 2018 (2). This will clearly impact our ability to support public infrastructure, education,
the arts, and so on. There can be no question that universal insurance coverage should be provided for
all U.S. citizens, and it is an embarrassment that the number of uninsured Americans approaches 40 million.
The need for malpractice reform seems equally obvious, as does the desirability of better information
techology. There should be greater reimbursement for evaluation and management services, which are
characteristically delivered by primary care physicians but also frequently provided by cardiologists.
Many problematic aspects of commercial insurance should be corrected, such as exclusion for pre-existing
conditions. Finally, we should incentivize quality of care, rather than quantity.
Although I have relatively firm opinions about the need for changes in health care delivery, I have no
comparable feelings about the specifics of how this should be accomplished. I shudder to think that
reforming these problems could cost as much as a trillion dollars, but I am uncertain that it can be
done for any less. I do not feel fully knowledgeable about the pros and cons of mandating everyone to
purchase medical insurance or appreciate all of the implications of a government option for health
insurance. I do not feel confident that I understand the nuances of providing premium subsidies to
individuals or to employers or the effects that changes in taxation related to health insurance would
have upon our system. I cannot say that I vehemently support or oppose any of the provisions of the
Baucus Bill or of the other proposed health care reform legislation.
As is so often the case, change is uncomfortable. This is certainly true of change in the health
care system, particularly when the specifics of the change are uncertain. We tend to resist change
and prefer that with which we are familiar, "the devil we know" as the cliché goes. So, although
I recognize our duty to society to provide the most effective and least costly care possible,
as is true of many Americans, I am inclined to prefer the existing system, which is familiar
and works relatively well for me. Perhaps this is why I have been reluctant to delve into the
details of health care reform: doing so would indirectly endorse a change to the existing system.
However, I am inclined to think that the lack of attention on my part and that of many of my colleagues
is due to something more fundamental. Regardless of the system in place, people will always become ill,
and it will be our role as physicians to treat them. Our primary goal will be to cure disease and to
relieve suffering, regardless of how this care is administered and paid for. Our major objectives
should be to ensure that patients have adequate access to the care they need, and that we have the
necessary support to deliver the best care possible. As for me, I am prepared to leave the details
as to how this is achieved to others, and pray that they know what they are doing.
1. The Lewin Report: An ACC Quality First Publication http://lewinreport.acc.orgAccessed October 26, 2009.
2. Centers for Medicare & Medicaid Services National Health Care Expenditure Data
http://www.cms.hhs.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.aspAccessed October 26, 2009