THE EXAMINING ROOM was small but comfortable. The two hour trip to the clinic and the wait were both familiar to my wife and I. Our four year old was on the floor flipping his hands in the repetitive behavior pattern familiar to parents of children with Autism Spectrum Disorder. A harried looking physician walked into the room with a medical resident in tow and hurriedly asked:
"Your son has treated here before, right?"
My wife and I looked at one another, wordlessly exchanging the identical thought:
"There must be a better way."
IF WE ARE a product of our upbringing, this diary is a testament to my father. A physician, he would ruminate on all things concerning the body politic while I was growing up. Discussion was topical and disagreement encouraged, save one exception. His favorite political metaphor was the first my young mind was able to grasp:
"Nero fiddles while Rome burns."
Universal health care was the exception to dissent. In My Father's House, God Forgive The Fool Who Spoke the Heresy of Socialized Medicine. To do so would immediately result in the Invocation of The Fallen British. Horror stories of Britons camping for days in hospital waiting rooms would ensue. This, he said, Intoning the Cleansing Mysteries of the Free Market, was The Price of Socialized Medicine.
Ironically my father grew up in poverty. He did not speak English until he began public education. He used a goal orientation nonpareil to finish both medical school and a residency in obstetrics. He then turned an innate ability to communicate and comfort patients into a private practice that by any conventional yardstick has been prolific and innovative.
The point is neither my father’s views on universal health ccoverage nor my experiences navigating a health care delivery system in disarray. Instead it is the literal and figurative bleeding of those who seek medical attention who are either under or uninsured under the current medial delivery system.
The nationwide problem has been documented: In the seven years between 2000 and 2007 the number of employer based health insured dropped from 64.2 percent to 59.3 percent. During this same period the number of uninsured Americans increased by nearly 20 percent, from 38.4 million to 45.7 million.
Families U.S.A. released a state by state analysis of the growing disparity between health insurance premiums and wages. Any interested individual can view the disparities specific to their state here. The gap for Texas , my home, is typical:
Health insurance premiums for Texas’s working families skyrocketed over the last eight years, increasing by 86.8 percent from 2000 to 2007
For family health coverage in Texas, the average annual premium(employer and worker share of premiums combined) rose from $6,638 to $12,403, an increase of $5,765
For family health coverage in the state, the employer’s portion of annual premiums rose from $4,879 to $9,191 (a difference of $4,312), while the worker’s portion rose from $1,759 to $3,212 (a difference of $1,453)
For individual health coverage in Texas, the average annual premium (employer and worker share of premiums combined) rose from $2,627 to $4,385, an increase of $1,758.
For individual health coverage in the state, the employer’s portion of annual premiums rose from $2,220 to $3,613 (a difference of $1,394), while the worker’s portion rose from $407 to $772 (a difference of $365)
The rise in premiums does not tell the complete story. Health insurance benefits provided by employers also shrunk during the period. Cost shifting from employer to employee in the form of higher deductibles and higher co-payments also continued. With less health care insurance benefits being available for more money, it is not surprising that a study published in the Journal of the American Medical Association has concluded that overcrowding in Emergency Departments in this country has not been caused, as has been commonly assumed, by uninsured patients.
The remainder of the Family U.S.A. analysis compares this eroding coverage and shifting costs of health care to stagnant wages. Again using Texas as an example:
Between 2000 and 2007, the median earnings of Texas’s workers increased from $23,032 to $26,484—a mere $3,452, or 15.0 percent.
Health insurance premiums for Texas’s families rose 5.8 times faster than median earnings from 2000 to 2007
The picture for the underinsured and uninsured in Texas is similarly problematic. In the maze of federal and state regulations, it is these children that are left behind. According to Census bureau statistics, in 2006 the median income for a family of four in Texas was $59,808. According to Barbara Best, Texas director of the Children’s Defense Fund to qualify for State Children's Health Income Program ("SCHIP") benefits in Texas a family of four must earn between $21,000 and $42,000. SCHIP requires parents to re-enroll their children every six months. Not surprisingly, many who would otherwise qualify fail to renew within this time frame. Officials struggle to process more than 3.8 million applications each year. Best was recently quotedon the choices confronting these families:
Most uninsured children have at least one working parent but don’t have employer-provided health insurance. It’s really tough choces: Do I pay for medicine or prescriptions, or do I pay the rent and keep food on the table.
The failure of employer based health insurance has been commented uponfequently. The worry is our continued failure to act. We fiddle while Rome burns. Universal Health Coverage is attainable, and the solution of a single payer system. There will be dissenters. I am sure in the nineteenth century there was similar dissent when a legislative mandated, government funded system of universal compulsory education became the norm.
During my father’s fifty year practice the old model broke down. Insurance reimbursements, charge backs and managed care marginalized his gift of bedside manner. The decision point for his services became whether he was within a patient's managed care network, not his ability to communicate and reassure them. He is resistant to the argument that a single payer system would eliminate most of the paperwork his specialized insurance employees must wade through each business day. He is also resistant to the notion that such a system would provide him greater opportunity to utllize his particular talent for patient care.
What he is committed to, however, is helping his grandchild maximize both the time and quality he spends with his physician in that examining room. This, I think, is a place to start.