month, I participated in a health-care reform debate, and
I ended up feeling that I’d left things unsaid.
First, I’d like to address the general mutterings that the
Democratic plan for a public option is “socialism.” Socialism
is defined as government ownership of the means of production.
In the proposed plan, medical care will remain privatized,
but people will have an option to buy insurance from the government
for that private system of medicine. Or, they can buy it from
Currently, private insurance companies are the sole arbiters
of health care delivery, leading to an inherent conflict of
interest. A company’s raison d’être is to increase its profit
margin. Nothing wrong with that if you’re selling shoes, but
health-care insurers profit by denying health care.
The public option would not have the profit incentive. Private
insurers typically have a 25-percent profit margin, whereas
a government insurer could put that quarter of your health-care
dollar directly into health delivery. That’s a lot of money
turned around into direct patient care. As a low-bid competitor,
the public option would force private insurers to lower their
premiums, deductibles, and co-pays—which would lower their
profit margins, but coming down from 25 percent to 15 percent
is a hardship for no one but the stockholders. And since stockholders
are patients as well, they’ll come out OK.
I’m not so naïve as to think any government bureaucracy will
get it all right. But a public option will change the playing
field so that the patients—the American citizens—get a fair
Which brings up another issue. The bill specifically states
that coverage is for American citizens. Of course we all know
the realities: There are 12 million illegals here, many of
whom use our health-care system, often in the emergency room.
Personally, I think there are moral and humanitarian reasons
for treating anybody who walks into an ER with an urgent problem,
but I can understand the resentment about unnecessary use
by people who haven’t paid into the system and don’t expect
to. Illegal immigration is a big problem, a drain on schools
and services, especially in the border states, and it must
be solved. But each one of these problems is so massive that
trying to combine their solutions into a single piece of legislation
is ridiculous. And disingenuous, if the immigration card is
being played just to waylay health reform. It’s like saying
the main street downtown is full of potholes, but bank robbers
use that street to make their getaways, too, so we can’t fix
the potholes until we solve the bank robbery issue. I say
let’s fix the potholes now, and next year we can try to deal
with the bank robbery problem.
In August, I had a patient just out of college who was working
as a teacher’s aide in an area preschool. She’d been walking
one of her kids to his mom’s car when someone’s big dog bit
her hand. It wasn’t officially on school property, so worker’s
compensation didn’t cover it. She knew she couldn’t afford
to go see a doctor—she was barely making ends meet, counted
pennies when food shopping—so she washed the wound, put Neosporin
on it, and hoped it would get better. It got worse.
When she finally came to my clinic, her hand was badly infected.
We’d customarily have charged $120 for a first-time visit,
another $190 for the wound repair I had to do, $41 for the
X-ray to make sure the bone wasn’t broken, $20 for the antibiotic
I had the nurse give her by injection, $85 for a tetanus shot,
and $50 for the nurse’s injection services. That’s more than
$500. I reduced her total bill to about $200, which I often
do for uninsured hardship cases. Even so, she had to borrow
money from her roommate.
But then I gave her prescriptions for two more antibiotics
to take by mouth, and she called from the pharmacy in tears.
One was $40—she could barely handle that—but the other one
was $180, and that put her over the edge. We finally worked
out that she would only take the one, cheaper, antibiotic,
and it might work alone or might not, and if not she was going
to have to come back in, and the problem might be a lot more
serious, might require hospitalization and intravenous antibiotics,
possibly even surgery.
I was giving suboptimal care. To a hard-working, vulnerable
young woman we were entrusting to teach our children. This
is happening every day to millions of Americans, and it has
to stop. And tinkering with the details of the private insurance
company monopoly on health care is not going to fix it.
James Kahn is an internal medicine physician practicing in
Santa Barbara, Calif. This article first appeared in the Santa