Public Comment

Some Thoughts and Questions About the Health Care Debate

By Kathie Zatkin
Thursday August 27, 2009 - 01:22:00 PM

Why aren’t reporters asking the following questions of those they choose to interview? This in-cludes the predictable “public television” (e.g., News Hour, Bill Moyers’ Journal) programs.   

When did “health” care replace “medical” care? If it’s all about preventing diabetes, quitting smoking, getting more exercise and eating less, are physicians really needed? Has anyone investigated or even dared question the claims about the huge numbers of diseases that are caused by these conditions or “lifestyle choices”? If every illness is classified as a lifestyle choice, what are the consequences? It’s easy to use language like “taking responsibility for your own health,” but all too often this is said or written with a sneer and little compassion—just another justification to “tut, tut” divert resources to “health education outreach” rather than hands-on care. Should we pay for the former rather than the latter? Why is it so difficult to actually talk about the costs of medical care? “Diseases” seem to have been replaced by “conditions,” leading me to the realization that treatment for certain conditions is comparatively easy to access—even from an HMO. Which conditions? The ones that have a drug or medical device associated with them. For example, the publicity about sleep apnea, which seems to have increased now that Medicare pays for sleep studies, apnea devices, etc.  

Why did it so easily become acceptable to not even discus the single-payer option? Insurance companies already make decisions about what “conditions” are covered and how long certain persons will have to wait for payment and care, and how burdensome it will be to actually get care or treatment. While insurance companies may not mandate how much time a physician can spend with a patient, insurance companies do provide “guidelines.” Physicians’ records are monitored, and compensation is tied to physician compliance. The companies that are paid for performance programs are big business. (See for example, Crimson Services, Physician Analytics.) It seems obvious that we already ration care. Why not be honest with patients? At least that might bring some trust back to the doctor–patient relationship. I know it’s optional, but I would rather have my physician able to bill for time providing medical care to me than counseling me about end-of-life decisions.  

“Evidence-based practices” is now a heavily favored concept, presumably because to be evidence-based means that the research on which the evidence was based was free from bias. Unfortunately, this is not always the case, especially with the rise of public/private partnerships. For example, NIH (National Institutes of Health) and SAMHSA (Substance Abuse Mental Health Services Administration) studies often have corporate ties, but these ties are neither readily disclosed nor easy to trace. The partner may often be an “advocacy” group on behalf of the population or group “afflicted” with the disease or condition, but pharmaceutical companies and those with a large economic stake in treatment for the condition that the “evidence” supports receive large corporate donations to continue advocating on behalf of these practices. Cure is rare now, but treatment, pharmaceuticals for life, and guidelines calling for earlier treatment based on evidence of “possible” risks abound. 

Who benefits from our donations? 

In spite of the above paragraph, assuming the vaccines have been researched, tested, and found safe and effective without conflicts of interest affecting the results, shouldn’t we pay for all children to be vaccinated against contagious disease prior to entering school? Why not bring back public health clinics and make them once again accessible to and used by all? 

How much money have we as taxpayers given to Electronic Medical Record Conversion/Establishment? What corporations are benefitting from this? In addition to privacy concerns that have been raised, are there other downsides electronic medical records? 

With electronic medical records, physicians now must spend time allotted to the patient visit electronically inputting the (not yet completed) visit into the electronic chart. If your physician spends more time looking at his/her computer screen and inputting data than examining you or answering your questions, perhaps it is because she/he is struggling to keep up with pay-for-performance guidelines/economic incentives. See below. 

One can no longer receive a paper prescription and shop around for the best price because “everything must be done online;” consequently only one pharmacy can and must be listed. Will it be more difficult to correct an error in a medical record? Will medical errors really be reduced if physicians, nurses, etc. still lack adequate time to read the chart—in whatever form? (See Snyder L, Neubauer RL, for the American College of Physicians Ethics, Professionalism and Human Rights Committee. Pay-for-Performance Principles that Ensure the Promotion of Patient Centered Care—An Ethics Manifesto. Philadelphia: American College of Physicians; 2007: Position Paper. If you are a member of an HMO ask directly how your physicians’ medical group/ health plan/insurance company is implementing these “principles.”)  

Medical insurance is not a new concept; neither is auto or fire insurance. Insurers have long been associated with for-profit companies, so it should not be surprising that there is a disincentive to pay claims. But knowing this, I think we might want to ask if we want to be part of a system where we know we are subjecting ourselves to this risk.  

An aside, too many of us make our living depending on the suffering or misfortune of others—a subject rarely if ever addressed/thought about.  

I am pretty confident that I am not alone in having these questions and that others have important questions that we do not hear. I guess the reasons for this are obvious. People are afraid to question out of fear of ostracism or mischaracterization or reductionism and because no one wants to answer these questions. 


Kathie Zatkin is a Berkeley resident.