the underwear drawer

so, health care reform




I've been staying away from this for a while because it's just such a divisive topic around these parts that I felt the better part of valor would be just to keep my head down and thoughts to myself. I would probably feel differently if I still lived in Manhattan (aka Liberal World *) but the fact of it is that I work in Georgia where I often feel that my political views are in the minority and thus in the interest of fitting in and not getting into crazy scream fights with people, I'd best just go about doing my job without the political side-conversation. But then the health care reform bill passed yesterday, and I've been writing this blog entry in my head all night. So here it is, apologies if it's rough, but this is not a multiple-draft proofread missive, I'm just spooling it out here.

The healthcare system needs reform, and I cheer the passing of the bill. There is tons that I could talk about, see here for more wonkish details (I am not the expert on this topic by any means, nor do I pretend to be), but the reason I stand behind the idea of healthcare reform is a simple philosophy, perhaps too jejune for most, is this idea: "The essence of civilization is that the strong have a duty to protect the weak." ** (In fact, I think that's part of what I was trying to say about the issue of vaccinating, which brings up very similarly contentious issues about personal freedoms and taking responsibility for others--not to stir that pot again.) "The essence of civilization is that the strong have a duty to protect the weak." Do I believe that? Yes I do. Working in medicine, this is a version of what we do every day.

This bill affects me personally, of course, though not in the same was as many people. For instance, I have health insurance. I make an income above what would qualify me for the expanded Medicare benefits proposed. In many ways, the passage of this bill into law will be detrimental to me personally, at least when it comes to my bottom line. When Joe starts making his attending salary and adds to our household income, our taxes will go up quite a bit. Decreased compensation for the work that I do under the Medicare reimbursement scale will mean that I make less money. (Anesthesia practice as whole is particularly vulnerable to this beyond most other specialties, see: "The 33% problem." For more, read this or other memos from the president of the ASA.) As the most junior member of a private practice anesthesia group, do I worry that such financial implications could endanger the very fact of my job? Yes, I do. I have two young kids at home, how could I not worry about it?

But--and again, I can feel that this is going to come off as irrepressibly naive, but to hell with it, as a young doctor, don't I deserve to play Pollyanna for a little bit longer?--there are bigger issues at play here. The world is bigger than just me and my family. Or even from a more selfish standpoint: it could be me. If there's one thing that Joe's bout with myocarditis this past summer taught me, even more than working with patients all day, is that as young and healthy and invulnerable as we may feel, we are all just one breath away from catastrophe. And if catastrophe landed in my front yard, wouldn't I be glad to live in a society that didn't just champion the notion of "every man for himself"? The essence of civilization is that the strong have a duty to protect the weak. Call it socialism, call it communism, whatever you like. I may be strong now, but I know that could all change at any point, and it gives me comfort to know that if and when it does, this is not a society that will turn its back on me.

Do I have reservations about parts of the bill? Of course I do, it's far from perfect. In particular, I am very nervous about any move towards cost-containment in healthcare (and of course it is undeniable that healthcare costs are, everyone's favorite verb, "skyrocketing") without addressing the incredible cost of practicing defensive medicine. The cost of malpractice insurance, performing procedures that tests that in all honesty do not need to be performed, the Cover Your Ass style of defensive medicine, all because anyone who has ever watched any form of daytime television can tell you that there are hoardes of slavering law firms out there ready and willing to sue your doctor for any old thing.

I am nervous about the prospect of undervaluing the work and expertise of doctors in the name of cost-containment, and the judgments made that paraprofessionals of all stripes can readily step into the roles that doctors once occupied for the simple fact that mid-level providers are cheaper. I don't like the idea that non-medical people may be making judgments on the importance or value of certain aspects of care, and I don't like the idea that hospitals and doctors may be penalized (general practitioners nonwithstanding) and devalued while being expected to accommodate the huge influx of sicker patients that this new law may avail of healthcare. And, of course, the size of federal deficit makes me nervous. I didn't even get a credit card until halfway through med school, because the idea of debt made me so uneasy. So there's that, too.

From a more detached point of view, though, it's really an interesting time to be starting out in my medical practice. Watching some of my more senior colleagues reacting to these imminent changes, part of me is glad that, as a rookie who just stepped into the ring, all I really know is how to do my job. (And even that, at times, is questionable. Kidding! Sort of.) But seriously, there are obviously going to be changes coming down the pike. What these changes will be and how they impact our lives remains to be seen, but I'll be here, and I guess we'll all figure it out together.

So the bill. It's not perfect. I don't love everything about it. But societally, it's a huge first step, and overall a good one. Not everyone agrees with me, particularly in this neck of the woods, but that's OK, we can disagree and listen and try to convince each other and then talk about it some more. And in the end, isn't that one of the key things about living in a democracy?


* "Don't you see the rest of the country looks upon New York like we're left-wing, communist, Jewish, homosexual pornographers? I think of us that way sometimes and I live here." -- Woody Allen, in Annie Hall

** This quote was taken from a speech by George W. Bush. Yes, you read that right. Of course, he was talking about something else, but still, the sentiment is generalizable.