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Public Need

Last 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 private insurers.

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 break.

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.

—Dr. James Kahn

Dr. James Kahn is an internal medicine physician practicing in Santa Barbara, Calif. This article first appeared in the Santa Barbara Independent.


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