Universal Healthcare

The other day, I saw a patient with possible tarsal tunnel syndrome. A few years prior, she'd had a ganglion cyst removed from the medial aspect of her ankle.  She did well until about a year ago, when she started noticing ankle pain radiating to the plantar surface of her foot.  On exam, I find nothing abnormal other than diffuse swelling.  The rest of her anatomy (tendons, joints, ligaments, neurosensory) is intact. It sounds a lot like tarsal tunnel syndrome by history, right?  What would your next step be in this case?  In my opinion, an MRI makes the most sense (perhaps an EMG to document the nerve conduction loss).  Prior mass, surgically removed, with recurrent symptoms - does she have a recurrent soft tissue mass compressing the tibial nerve?  Well, here's the challenge: after a recent divorce she has no health insurance.  Now what?

Many of us are seeing increasing numbers of cases like this: patients who need care but are unable to afford the associated medical expenses.  Would a universal healthcare system eliminate these problems?  What new difficulties would this system introduce?  Would physicians be the winners or losers in this scenario?

Obviously, I'm not an expert in national healthcare systems, and I don't pretend to have even the vaguest shadow of a hint of an answer.  However, I do have an opinion (What else is new?  Shapiro has an opinion).  Let me state at the outset: I am a proponent for universal healthcare.  I'm probably very much in the minority, writing to physicians, but I think it's important for you to be aware of my bias.

As a young doctor, I did not grow up in the "good old days" of medicine when, as several of my older colleagues tell me, physicians were paid significantly more for their services than we are now.  I'm sure for these doctors, making less than they did previously is a hard pill for them to swallow (it would be for me as well).  In the case of us young docs, perhaps ignorance is bliss—we don't know what we're missing.

My concern, though, is not with physician pay—important as it is—but rather providing our entire population with healthcare coverage.  In the wealthiest country in the world, why do so many of our fellow citizens not have healthcare?  The Organization for Economic Co-Operation and Development published a study February 2009 regarding healthcare in the United States and how we compare to the 29 other members of their organization.  See www.oecd.org for information about the OECD. Their study turned up some surprising data. 

1.     US overall life expectancy, though increasing, is increasing at a rate lower than many of the OECD members.

2.     There is an increasingly large gap between life expectancy of socioeconomic groups in the US vs. other OECD members.  This is contrary to the stated goals of our US Health and Human Services Department.

3.     Infant mortality rates in the US (7/1000 live births) are higher than the OECD average (4/1000 live births).

4.     Total healthcare expenditures per capita were significantly higher in the US than other OECD countries. 

5.     Physicians in the US earn greater incomes than most of the OECD members.

6.     More advanced technologies such as MRI and CT are available in the US (ex. 26.5 MRI units/million people) than any other country other than Japan (ex. 40.1 MRI units/million people).

So, in spite of our higher spending for healthcare than other industrialized countries and access to expensive doctors and technology, our health outcomes are significantly poorer compared with these other countries.  Is this due solely to a lack of universal health care?  I don't know.  I do find it suspicious, though, that of the 30 countries who participate in the OECD (most of which have better outcomes than us) only three do not have universal healthcare: the United States, Turkey, and Mexico.

Additionally, as the economy worsens and more people become unemployed, more of our citizens will become uninsured, leading to increased use of emergency services or deferring care, with potentially more advanced disease and associated cost.  We're all well aware that health insurance coverage has become a significant portion of business operating costs.  How, for example, can US car manufacturers compete with the Japanese, when a significant portion of their costs are for healthcare?  Obviously, this isn't the only reason for their failure, but it is a significant expense for private industry.  For those of you physicians who still provide private healthcare to your employees, wouldn't you rather eliminate this cost from your balance sheet?  According to the National Coalition on Health Care, employer-based healthcare costs rose 5% in 2008, two times inflation (http://www.nchc.org/facts/cost.shtml).  
We also know that rising healthcare insurance costs are a major reason for personal bankruptcies in the US.

With all of the effects healthcare costs have on our society, is universal healthcare the answer?  I think it must be at least part of the answer.  The system we have now is neither efficient, affordable, nor sustainable.  We need a change soon, or our system will eventually collapse under its own weight.  What are your thoughts on universal healthcare?  Panacea or pickle?  Write in with your thoughts and opinions. 

Keep writing in with your thoughts and comments...we'll see you next week. Best wishes!

Jarrod Shapiro, DPM
PRESENT New Docs Editor
jarrod@podiatry.com

In response to PRESENT Podiatry New Docs 136- Universal Healthcare by Jarrod Shapiro 3-24-09

While I have great respect for Dr. Shapiro and thank him for his contribution to PRESENT, I must reply to a few of his comments on Universal Healthcare.

Firstly, the OECD report is biased toward wellness.  The US has the best "sick care" system in the world.  When you need an organ transplant, require cancer treatment, or need to be separated from your Siamese twin, there is no better place in the world to be treated than the US system.  The US does a less than perfect job at wellness or maintenance of health.  While other developed countries may do a better job of promoting wellness, it takes 6 weeks to get an MRI (England), or months to see a specialist.

Secondly, doctors in the US receive higher incomes since our training is different (mostly longer), there is significant liability (not present in other countries), and the cost of medical education is higher than any other country (increase of 720% since the early 80's).  So you may be a proponent of reducing physician compensation as a altruistic approach to care help contain the cost of US Healthcare, but who is going to pay your loans and malpractice? There are already too many financial disincentives to becoming (and staying) a doctor.  Why would any bright young person want to enter the field of medicine when they can make more money in another field without spending 11-15 years in education?  The answer is .. they wouldn't.  There will become a "brain drain" in medicine.

It would be a perfect world if everyone could receive healthcare coverage.  But there has to be some personal responsibility.  In cases where one cannot afford coverage or other circumstances, there is currently a welfare system.  We currently have a private system driven by capitalist ingenuity and incentives.  Give that up, pay doctors $120,000 per year, pay their medical school, cover everyone for care, and then you have SOCIALIZED MEDICINE.

Lee C. Rogers, D.P.M.
Director, Amputation Prevention Center at
Broadlawns Medical Center
1801 Hickman Road
Des Moines, IA  50314
Lee.C.Rogers@gmail.com
www.Broadlawns.org
www.diabeticfootonline.com

I am writing in response to your article on universal healthcare.  Didn't you practice in Michigan for several years?  How many times did you see Canadians traveling across the border to seek health care in a timely manner that they were not able to receive in Canada?  I cannot count how many times I have encountered this in my practice.  Just several months ago, I had an 80 year old Canadian patient with weeping venous stasis ulcerations, edema, and arterial disease come to the office to be treated because the waiting time in her country was 6 months to see a vascular surgeon and to even get vascular testing performed.  Her primary care doctor did not treat this type of problem, so she was told to wait until she could get into the vascular surgeon.  I know for a fact I could have one of my U.S. patients scheduled for vascular testing within a week and probably have consultation with the vascular surgeon within 2 weeks time.  2 weeks vs. 6 months.....quite a discrepancy.
    

In addition, any given day at the Detroit Medical Center you will find Canadian citizens being treated for cancer, orthopedic conditions, cardiovascular disease, etc.  If healthcare was so accessible and so good in their country, then why are they traveling across the border to the U.S.?  I am curious to hear if any other doctors living in an international border zone have experienced similar situations?  I am sure these Canadian citizens are not coming to Detroit as a prime vacation destination!  We have the best health care system in the world with the best access to health care.  I am sure we could improve upon what we already have, but universal healthcare as most people know it, is not the answer.  We need to work on ways to make health insurance more affordable to all and decrease premiums through competition and incentives.

As a physician, it would be tempting to see a certain number of patients per day and have the government pay me.  To be rid of the hassles of dealing with the different insurance companies would be wonderful.  As a patient, I want choice, accessibility, and the highest quality health care available.
 
Sincerely,
Angela Renshaw, D.P.M.

You have some interesting points. Nobody is leaving this country to have surgery or medical treatment in other countries with socialized medicine, because you are put on a list and may have to wait several months to a year for treatment.  If we want to socialize medicine, lower the cost of the education. 100 thousand is a little high when you will never be able to repay it. Why not free education? Maybe shorten the time needed to get the degree. Surely you don't need to know everything to practice. Trimming corns and calluses... maybe a week or so. Toe nail surgery, another week. Warts a day. Don't forget about doing away with liability. If we can't pay for services, why would you get money if it wasn't done correctly?  If you really like socialized medicine, why don't you go work in a third world country and really help the people. Don't live in the USA where we ask for people to pay for services. There is currently a system of socialized medicine in this country in the Indian Health service. Ask those people how they like it. You get what you pay for. When something is free maybe it’s not worth anything.

Have a good day. Make sure you pay your student loans on time or someone will be knocking at your door.

William Smith
sipopy@cox.net

I don't think you are in the minority.  I agree with you, but then again I am a doc young like you.  I believe universal health coverage would benefit both the patients and us.  Heck it can't get much worse than it is now...well, never say never.

Most docs I have spoken to lean toward universal healthcare.  AMA supports it.  The APMA supports it.  I believe that the private insurance companies (who will largely be put out of business) are the ones spreading the rumor that "doctors" are against universal health coverage!  Or, maybe I am just a conspiracy theorist!  Or, maybe its because i live in northern California.  Haha!

 

Alanna Wargula, DPM
alannapod@gmail.com

Just a quick rebuttal to your article for new docs regarding universal healthcare.  I certainly appreciate your arguments, though I think that a forum such as this one is not an appropriate venue for the dissemination of one's personal politics.  If you feel I am being harsh with this, please refer to your earlier article regarding 'green' surgery suites. 
 
I found your source of information for your recent article to be obvious, considering your bias.  As you are probably aware, the OECD, which was spawned originally from the Marshall Plan after WWII has always been one of the largest proponents of left leaning socialism since the war.  OECD is also very politically active all over the world, so to assume that by putting a .org after its name makes it unbiased is, as you know, very thinly veiled. 
 
Judging by your stated bias, which I appreciated, it would be a natural progression to gravitate toward quoting from this obvious left wing, european socialist organization.  But as always, the devil is in the details, and the OECD is hardly innocent of 'fudging' the numbers.  Arguments such as the life expectancy gaps are not based on medical received, but rather lifestyles, which, if you have ever spent any time in europe, is much healthier in terms of diet and exercise than our own country.  The gap between life expectancy groups among socioeconomic classes are another distortion:  Recently, in most european countries with socialized medical systems, privatized insurance systems have been cropping up.  Doctors in socialized countries are seeing regular patients during the week, and seeing privatized patients on the weekends, where they can make more money.  This system is also a natural progression when a socialized system begins to fail, resulting in rationing and triage.  When this occurs, only the very wealthiest can afford to pay for the best healthcare.  This was vividly realized during the Clinton administration, when rich Clinton friends from Canada came to the US to undergo life saving heart surgery.  So much for care of the great unwashed masses.  I think you understand my point. 
 
Infant mortality rates in the US fall well within the margin of error in comparison to well-developed european nations. However, since the OECD has recently began to add less developed countries to its organization, that number falls precipitously in comparison.  Again, another example of making the numbers fit your rationale. Hardly 'hard' scientific evidence.
 
Total healthcare expenditures are an area that both you and I could agree with, at least superficially.  As Richard Gephardt said, just this past weekend at the APMA conference in Washington DC, and I paraphrase:  "Should an eighty year old man be treated for his slow growing prostate cancer, or should that money be used (read rationed...) for a younger patient in need?"  Already they are talking about rationing in Washington, and we have not yet implemented this heretofore failed system of universal healthcare.  So, since most medicare dollars are paid in the last few years of a patient's life, it would be better, for all of us, just to let them die.  They are, after all, just going to die anyway.  Rationing, and worse, triage, seem hardly the humane way to universal treatment of all patients.  Certainly, your patient, with the benign symptoms of a soft tissue mass or sinus tarsi syndrome, would likely wait months, if not years to be seen for the problem, let alone treated.  At least according to the British system. 
 
One might query the wisdom of putting 17% of the US economy under the auspices of the US government, considering they cannot even balance their own budget, and if Medicare is universal care in microcosm, then certainly we can all appreciate the reasons from steering away from this course of action.  Especially when dealing with an economic recovery.  FDR tried this with the New Deal.  It failed.  Thank goodness for WWII which saved his economic reputation.
 
What is more concerning to an ignoramus like me, is the danger that such superfluous arguments entail.  It is much like the banning of DDT, which directly resulted in the deaths of millions of children in Africa and other developing nations.  The argument from the left is always "Well, we meant well..."  I find this argument harrowing when I think about it, and my children as well.  I suspect you might feel the same.
 
Now, if you have managed to get through this largely incoherent and extemporaneous response to your article, then I thank you.  Certainly subjects like these should promote a healthy banter back and forth.  Thank you in advance for your consideration, and I hope everything has gone well with you in Oregon.
 
Truly,
 
Clinton F. Holland, DPM
Englewood, CO.
rivenrent@yahoo.com

I thought I would give you my two cents worth.
 
Australia has a “universal health care system”. It is called Medicare. I do not wish at this stage to give you all the details as these things are always complex.
 
Here in Aus, all those who work pay a Medicare levy of 1.5% percentage of their taxable income, and access to Medicare is available to all and sundry. High income earners pay a higher levy. We have medical centre’s who bulk bill the government and the patient pays nothing. Other GP’ will charge whatever and the patient has to pay the difference between their medicare rebate and the actual charge. Pensioners do not the pay the levy .  X rays taken for “out patients” and emergency are free but other X rays are paid in full by the patient who then claim from MEDICARE. The rebate is a percentage of the “schedule fee” for that service, which works at about more or less half of the amount charged. Diabetic Footcare has recently come under the Medicare umbrella
 
MRI is a very vexed question. They are not rebatable under MEDICARE nor can you claim from your private health insurance. MRI’s is considered to be an excellent diagnostic tool, but oversubscribed and the mood out there is that it has made practitioners lazy for not using other available technology.
 
The upshot of our universal health care system, is that it is abused, overused and medical centres are making a killing from the system. The Medicare levy only funds the cost by 50%. The tax payer picks up the rest. To its credit, medical care for the poor, down and outs and other unfortunates is accessible and available and is of high quality. In my view, there is ample funding for health care. It is just poorly and ineffectively distributed. Imagine the costs of just managing the FDA!
 
A classic case of abuse in your country is the reimbursement for pedorthic footwear and inserts through the Therapeutic Shoe Bill. It should have been mandatory (not optional) from the beginning that recipients co pay for their treatment. Here eligible war veterans who have a clinical need are supplied with approved medical grade footwear. I am not alone in thinking that these veterans should have had to make a co payment, but it is too late for this now.
 
My philosophical position has always been that people must have equity in their health, so they should always be prepared  to pay towards their own up keep. People insure their houses, cars, boats and any other material thing of value, but wants the government to pay for their health. Australia, like the USA has an endemic position on obesity and type 2 diabetes but the healthcare system has to take care of them. They can afford to pay for junk food, but cannot pay for their health.
 
With kind regards,
 
Casper Ozinga, C. Ped (Au), C. Ped, (USA)
Certified Pedorthist
 
Comfort and Fit Australia Pty Ltd
1/81 Darley Street
Mona Vale  NSW  2103
Australia
info@comfortandfit.com.au

Universal Healthcare – Editor’s Response
    Without doubt the concept of universal healthcare is controversial and is not likely to be decided to everyone’s desire.  In the spirit of brevity I’m going to attempt to reply to the above submissions in one response.  Again, I thank those who submitted thoughtful arguments.  All of our opinions matter and deserve to be heard. 
    First – some housekeeping.  I disagree with the above assertion that this is not an appropriate venue to discuss personal politics.  As we’re all aware, this editorial is an opinion piece rather than a scientific resource.  I ask no one to agree with my viewpoints – in fact the part of writing Practice Perfect I most enjoy are the opinions and responses from the podiatric community.  Of course, the subjects we discuss need to be topical to us as podiatrists.  My opinions on something like the pro-choice vs. pro-life debate would in fact be inappropriate as this topic does not pertain to podiatry.  But nothing is more topical and significant to podiatrists than universal healthcare. 
A comment above was made regarding Roosevelt’s failed economic policies.  I don’t want to turn this into an argument about The New Deal, but it’s very easy to make generalizations (“FDR tried this with the New Deal.  It failed.”)  This is in fact a hotly debated topic even to this day.  Suffice it to say that the FDIC, the Securities and Exchange Commission (SEC), and Fannie Mae (very successful until recent deregulation and speculation) come out of this “failed” program.  Let’s not forget Social Security (something no one wants to see eliminated). 
It was mentioned that the AMA and APMA support universal healthcare.  According to Dr Nancy Nielsen, president of the AMA, “We oppose a single-payer system and other proposals that move our health care system in the wrong direction.”  She goes on to say, though, “Standing pat, however, is not an option. The current state of our health care system is not sustainable. Over the years, our AMA House of Delegates has adopted sensible policies that outlined reasonable reforms that will benefit all stakeholders. We are using these reform objectives to guide us in the current debate. They include:
•    Expanding affordable health insurance coverage for all;
•    Reducing costs and increasing value in health care services;
•    Eliminating excessive administrative burdens;
•    Increasing investments in wellness and prevention services;
•    Empowering physicians to improve quality through evidence-based medicine;
•    Reforming government insurance programs by providing adequate physician payments to assure timely access for patients;
•    Implementing essential payment and delivery reforms to optimize health care expenditures, including medical liability and antitrust reforms.
http://www.ama-assn.org/ama/no-index/news-events/rhetoric-reality-st
imulus-package.shtml

This is a succinct summary of the important goals of healthcare reform in the United States.  I’d like to invite the APMA leadership to provide us with a statement of opinion on this topic. 
    Now, onto the argument! I think we can all agree that the current state of medical health coverage in the United States is slowly crushing the country.  Most agree, whether conservative or liberal, that something must be done.  What we do is up for debate.
    I agree that the United States has the best acute care treatment and technology in the world.  My argument is more with healthcare access and cost.  I have no desire to destroy the capitalistic drive to create new technologies; our competitive drive is part of our success.  However, eventually the rising costs of healthcare will eventually make it cost prohibitive to utilize new, initially more expensive, technologies.  We need to integrate our current strengths into a modified system.
    Whether the OECD is “left wing” or “socialist” doesn’t change its validity.  Bias exists in every source we quote.  It was mentioned above, “Why would the United States, a superpower among nations, be interested in being compared to 29 other member nations as a measure of the effectiveness of our own health care system?”  I appreciate the nationalistic pride expressed in this statement, but the US is a founding member of the OECD.  Why should we have concerns about being compared to other countries?  We don’t have anything to hide, and we don’t seem to have any trouble enjoying a comparison when it’s in our favor.  Why can’t we examine what other countries do and adopt what works while disregarding the failures?  I view those other countries as experiments in various health systems, where we can learn from their failures without ourselves suffering the consequences.
About the NCPA.  This is actually a nonprofit conservative think tank.  You may say they’re bipartisan, but they’re not.  The founder and president of the NCPA was John Goodman, “Father of Health Savings Accounts.”   I don’t imagine that someone this closely linked to private insurance would have a bias against a national healthcare system.  They’d have nothing to lose, right?  Bias can be found on both sides of the argument.  Someone smarter than me once said to look at both sides of the issue and use history as the guide.  I think that’s good advice for all.
I have never seen a patient coming from Canada for podiatric care.  I have, though, experience with patients who’ve driven to Canada and Mexico for cheaper prescription drugs.  My in-laws, in fact, travel regularly to Mexico to buy cheaper medications. Americans do travel to other countries for medical care.  According to a New York Times article, “At least 85,000 Americans choose to travel abroad for medical procedures each year, according to a recent report by the consulting firm McKinsey & Company.” (www.nytimes.com/2009/03/21/health/21patient.html?_r=1&ref=healt
h).  
I love this country as much as everyone else, and I want to see us succeed.  However, I don’t understand why so many people I speak to become so defensive about this issue.   We can love the USA and still criticize the USA.  We are not above reproach.  In fact, it’s our jobs as citizens to question the status quo, which is why we’re having this discussion!  So, again, I think we can agree at least that something has to be done.  I also agree that whatever system is chosen should not alienate providers.  The system has to workable and beneficial to physicians.  We are the providers of healthcare.  I agree with Dr. Rodgers that this profession has to be profitable or potential caregivers will go to other professions.  I also agree that whatever solution we choose doesn’t have to be a socialized system.  I want one that works.
But are physicians really that profitable under the current system?  I hear only complaints about poor reimbursement from both private insurers and Medicare/Medicaid.   Do we really want it to stay the same?   I would argue that from a monetary standpoint medicine is already not profitable for physicians (if you take into consideration the education commitment, money, and stress).  We do it for many reasons, not just the money.  I’ve heard strong arguments from our responders, but what I haven’t heard yet (including on the national front) are solutions.  What changes do you want to see if any?  If President Obama asked you to solve the healthcare crisis what would you suggest?
Here are some thoughts on what should be done at least to start:
1.    Use the medical research system that we know so well.  Set up smaller experiments around the country.  Let’s figure out on a microcosmic scale what works and what doesn’t.   They’re doing this in Maine as we speak. 
2.    Streamline the administrative process.  Force any medically related company to decrease its administrative processes and increase their transparency.
3.    Make insurance company coverage decisions and rate calculations made public.
4.    Eliminate the concept of “preexisting conditions.”
5.    Have a nationally televised healthcare summit with all the players involved.  I haven’t heard much from the recent one that occurred.

This is a monumentally large problem that breeds strong responses and will likely require difficult solutions.  My deepest respect to all of you who are participating in this discussion.  Successful solutions do not come from tepid emotions.   Write in and contribute your thoughts on our healthcare crisis.