For those among us that have a vague recollection of a time when the US health care system was different and when it began to change, Dr. Victoria Sweet presents a gentle reminder:
The almshouse was how we used to take care of those who didn’t have health insurance. Every county had a free county hospital for the acutely ill, and a free county almshouse for everyone else who needed care.
Beginning in the 1950s, however, first the county almshouses and then the county hospitals were closed, for reasons of economy (as demanded from the right) and social justice (as demanded from the left),...
Clearer to me were the days of the dreadful state mental institutions that Ronald Reagan and liberal "do-gooders" closed in favor of small, local, residential, mental health care facilities. Except we didn't build those alternative facilities and released those in need of better care to live on the streets where everyone can either ignore or complain about homelessness and not do much about the underlying problem.
On God's Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine
"Victoria Sweet writes beautifully about the enormous richness of life at Laguna Honda, the chronic [care] hospital where she has spent the last twenty years, and the intense sense of place and community that binds patients and staff there. Such community in the medical world is vanishingly rare now, and Laguna Honda may be the last of its kind. . . . God's Hotel is a most important book which raises fundamental questions about the nature of medicine in our time. It should be required reading for anyone interested in the "business" of health care--and especially those interested in the humanity of health care." -- Oliver Sacks
Liberals will likely enjoy reading Dr. Sweet's accounts of her experiences at Laguna Honda Hospital. Will also join her in advocating for more of what Dr. Sweet calls “slow medicine.” However, I doubt that they will be enamored with her prescription for reforming US health care. Why? Because it contradicts what has been accepted by those to the left of neo-liberal Democrats as the solution to what ails US health care: single-payer. Even the brilliant Dr. Steffie Woolhandler who clearly sees and articulated in a Democracy Now interview much of the folly of “RomneyCare” is a single-payer advocate.
Much of the Massachusetts plan has been wildly expensive. According to the state’s report to its bondholders, it’s cost $1.3 billion this year. The state has opted to pay for that by stealing money from safety net clinics and hospitals, so that safety net providers that care for immigrants, the mentally ill, people with substance abuse, that provide primary care, they’ve seen their funds shrunken, so that money could be handed over to purchase insurance policies. Massachusetts now has the highest healthcare costs in the history of the world.
As I pointed out at that time (11/12/09)
There is no path to affordable Universal Health Care in the US as long as we persist in believing that insurance is the answer -- the only answer. Getting a third of the population into a federal public insurance pool wouldn't have worked because it left in place capitalist medicine. The cost of health care in the US is excessive in relationship to wages. Insurance has help mask that inconvenient truth. Price controls haven't worked for Medicare (the most expensive health insurance program anywhere on earth) or for health insurance companies. No reason to think that a new insurance agency would do any better.
Dr. Victoria Sweet now utters words that I implied but refrained from directly stating in my numerous (and mostly unread) diaries on health care: two-tiered. The egalitarian in me recoils at the suggestion of two-tiered system of health-care in the US. Yet, in what area of our lives in this country do we not have multiple tiers for basic human needs? Housing, food, transportation, education, etc? Reluctantly but financially or economically
concluding:
We can no more afford our foreign adventures than we can afford 17% of GDP on healthcare. Pretending we’re a middle-class nation doesn’t make it so. And as Barbara Ehrenreich points out, positive thinking is positively disempowering and destructive. How can we not see that US public health facilities, Community Health Clinics and free clinics are the only viable key to expanding access and affordability to the tens of millions of Americans that have been left behind by The Best (and most expensive) Health Care in the World?
Dr. Sweet's words are now a symphony to my ears:
Although the Affordable Care for Americans Act has been law for over a year, it is still controversial: almost every poll shows that 43 percent of Americans approve of it, 43 percent disapprove, and 10 percent don’t know what to think. Having just finished reading it, that’s exactly how I feel.
She goes on to say:
There is a lot to like about the act, especially its general ideas: that people should not lose their insurance when they get sick; that insurance companies should spend 85 percent of their revenue on patient care; that counties should take care of their sick poor. But as I read, I began to get cold feet.
The health-care law is not one law but hundreds of laws, mandating thousands of new regulations, hundreds of new reporting tools, and countless new departments, divisions, and committees. There are laws about the minority workforce and oral-prevention activities, about elder justice and buying trailers for clinics. Each of the new laws requires hundreds of supplemental pages to detail. (The final Rule for Section 3022, implementing the “Accountable Care Organization,” is 696 pages long.) And some of the best ideas are undercut in the details, so that insurance companies don’t really have to spend 85 percent of their revenue on patients. The more I read, the more the ACA struck me as a portmanteau of social-justice initiatives and compromises with the insurance and drug companies, having little to do with insuring all Americans.
How she has punched through what's wrong with ACA and not stopped at “single-payer” is her story and one few practicing physicians today have experienced.
I can’t help but reflect on the imperfect but good-enough system I’ve known in San Francisco, and wonder what would happen if we turned it back on nationwide— reinstituted a county hospital and a county almshouse in every county in the country. They wouldn’t be fancy, but they would be free, and anyone could go—even the rich—as long as he or she was willing to take a number and sit on a bench.
Most likely those free hospitals would be used as they always were, mainly by the poor, while everyone else had the security of knowing they would not face bankruptcy if they lost their insurance.
Or perhaps not. Perhaps they would be inundated by patients who, preferring a good if imperfect system, voted with their feet. What then? Then we would have a real solution to our health-care crisis. Because the for-profit system would have no choice but to do a better job than the free county system, or it would simply disappear.
IOW – it's the for-profit health care system, stupid.