Wednesday, August 19, 2009

My Head Hurts Too

The health care debates are starting to fray my nerves. I have patiently waited on the sidelines, cooling my heels, doing what every well-meaning American should be doing, thinking about what change in health care portends for our great nation. Where should one start? At the outset, one must decide whether the ability to receive adequate health care in our society is a right or a commodity. A friend, Don S. has commented on earlier observations I have made on this issue and his position, I think, is genuinely reflective of those who are opposed in principle to “Obamacare. Don states, ”My primary objection to this healthcare reform is as much philosophical as it is a fear of losing great healthcare coverage and bankrupting the country. Some of stronger faith than I believe the government can do a better job than the private sector, I do not. While I believe we do need some sort of Healthcare Reform this isn't it. . .”

As I answer that question for myself, I need to focus on the subject of denial. Denial is a pathologic thought process in which its sufferer refuses to look at critical facts, the net effect of which, of course, results in a refusal to deal with the obvious. The diatribe that follows is my assessment of the denial existent in our current health care crisis that has manifested itself for years in its various forms. I remember my earliest medical school days at teaching rounds at the University of Michigan Medical School in the mid-sixties. On those occasions the students were taught that they should refrain from referring to uninsured black patients as "crocks." The issue of whether a white patient was insured or not was never discussed or considered. Stated another way, even in the earliest ventures into medicine, those with black skins had a label attached that carried with it the suggestion that they just might not be entitled to the quality of effort that white folks received. Did that make a difference at that level of medicine? Absolutely, because black patients became the opportunity for young developing physicians to practice various techniques, such a plunging a needle deep into a femoral vein to obtain the morning blood sample rather than take the time to find a good vein in the arm. A new student, prompted by those above him in the chain of command, would never dream of doing such a procedure on a white person. If one was black, everyone in the chain from lowly student to intern to medical resident to staff to professor simply knew that somehow he/she was in the hospital because of his/her excessive use of alcohol and that their treatment was being provided gratuitously. In short, a moral judgment was made at the outset of medical treatment that black people were undergoing a disease process their behavior had caused, an assessment never to be applied to white people. In that time frame, as now, the average medical student was exposed to the concept of alcoholism for one hour in a lecture early in the second year of medical school. A crude estimate, my own backed by some pretty solid statistics, is that then and now more than fifty percent of all medical visits to doctors or hospitals result from the medical complications of the abuse of alcohol in all people, white or black or shades of skin color in-between.

For awhile during this era, I paid for my medical school tuition and fed my family by performing physical examinations at a small hospital. I remember vividly being threatened with the loss of my job because after the workup of the wife of a prominent local businessman, I put my first three impressions as follows: 1) acute alcoholism. 2) chronic alcoholism and 3) rule out gastric ulcer. The patient had reported to me that for the three years before this hospitalization she had been drinking a fifth of vodka daily, but had increased her usage to nearly two bottles daily in the two weeks prior to admission. She was admitted because she started to vomit blood. I was told by the hospital administrator to change my written report because the woman's insurance would not pay for her medical treatment if the diagnosis was as I had stated. The woman's private physician called and yelled at me for putting this "label" on her. I made the changes and didn't argue about it. Denial, the primary symptom of alcoholism, extended far beyond the user to the system itself. That inherent fault in the system is intact today.

Flash forward nearly ten years to the early 1970s. The attitude had not-so-much changed as shifted to include drugs, particularly heroin, in the analysis. By then, I was the director of substance abuse services for the Michigan Department of Corrections. As a basic statistic, it was well known that more than fifty percent of all persons under the supervision of the correctional system (prisoners, probationers and parolees)were involved with the system because of their abuse of alcohol or drugs, usually both. I designed a treatment program for anyone in the Michigan correctional system. The hook of the program was that the prisoner/parolee/probationer had to contract with the Department of Corrections to alter their use behavior to gain early release or reduced supervision. Two years after the treatment program started, it had reduced the recidivism rate by more than sixty percent, but the federal funding for the program was discontinued and the Department of Corrections dropped the program. Knowing that federal funding was ending, I had approached several large insurance companies and asked that they consider establishing a program to insure those who my program successfully rehabilitated. I was literally laughed at for making the absurd request. In the same time frame in a discussion with the chief of medicine at Harper Hospital in Detroit, he told me that physicians did not treat alcoholism because it was a sociologic problem and not a medical disease. Denial in another form exemplified.

My point in mentioning my early experiences is to emphasize and illustrate that there is a long standing and fundamental knowledge that not only criminal behavior, but many, many, many (note well the three 'manys') medical problems are caused by excessive drug/alcohol patterns of use that insurance companies and the medical profession have never been willing to accommodate, much less acknowledge. But to do something about the problem, to recognize it as such, is verboten because of the risk of triggering the 'uninsurability' wrath of the insurance industry. The built-in denial has a rational basis if one's orientation is to increase the profitability of running an insurance company or maintain an economically viable medical practice.

As my professional live evolved in the mid-1970s to that of trial lawyer, I became profoundly interested in the adverse effects of prescription drugs on users. If there is one major conclusion that can be drawn after nearly thirty five years of law practice in this specialty area, it is that most adverse drug reactions, minor or severe, go absolutely unrecognized by treating physicians. As an example, a recent study published in a responsible journal concluded that there were 28,000 deaths in Michigan each year due to adverse reactions to prescription drugs. Less than 10% of these incident were reported as such in the medical records of those who died. The one hour lecture on alcoholism during the sophomore year of medical school occurs within the framework of the one semester course during that year in pharmacology, the study of drugs. For the remainder of their professional lives, physicians learn to rely on what drug companies tell them about drugs. What do they learn in that process? Not much. The ignorance of physicians in this area, in conjunction with the likely legal responsibility, automatically guarantees denial as a major force at work. To illustrate my point in the context of the current discussion, insurance companies will pay for psychiatrists to adminsiter drugs to patients, but will resist paying for what the patient really needs, i.e, mental health counseling.

Now what does this diatribe mean in the context of the health care plan? Alcohol and drugs, illicit or prescriptive, and racist-tinged patterns of treatment are only part of the problem. Our society has learned a great deal about the roles of smoking, exercise and proper nutrition in the health of our nation. One of the criticisms that has been voiced about the Obama health care plan is the fear that people will be punished because they are overweight or smokers or because they do not like to exercise. In short, the public wants it both ways. They want to be able to continue to eat, drink, smoke and vegetate in front of a TV set for hours each day, but they want others to pay for it without recognizing or acknowledging the role of their own behavior in creating their health status. In other words, denial is the major symptom of our current health care system across the board, patient and doctor. To deny the existence of denial is to deny the premise that access to medical treatment is something other than a commodity to be purchased, each according to his/her economic levels. I maintain that full and complete access to all aspects of medical care is a right rather than a privilege of economic class or ethnicity. But the roles of all, particularly the patient, must be defined in terms of accepting certain responsibilities for one's own health status.

Don comments again, “Again I will agree we need some reform in Healthcare but one that has ABSOLUTELY NO GOVERNMENT CONTROL over the Healthcare we receive, leave that to the patient and physician. Can you imagine the bureaucracy this is going to create in Washington and how many more Public Employees there will be in th is country. Who's going to pay for it??? If the Dems succeed and pass a Bill that moves us towards a Single Payer Healthcare System (as our President has said he wants on a number of occasions) I can see the politicians rhetoric in the future for raising taxes. Kind of like the states; if we don't raise taxes we will have to close down prisons and release all kinds of criminals into the neighborhoods, lay off teachers & state police. Instead it will be even more sinister like, stop vaccinating children, cut down on your prescription drugs, eliminate life saving procedures, basically saying you will die if we don't raise taxes.” And “Unlike you I do not believe this is an organized effort by the Insurance Companies. I could be wrong but if they are involved the grassroots movement is having a much greater impact. I have been to 2 Tea Parties and mingled with the Mobsters and can tell you first hand nobody told them to participate and raise hell, they are just common folk.”

My response is that I believe the health care insurance industry has paid millions of dollars to public relations firms (just as did the tobacco industry) to find the rhetoric and cliches that push buttons of people who are ideologically inclined in the first place to oppose Obama on just about any issue, big or small. For example, "hands off my health care" is a slogan that feeds off anti-government sentiment and does not take into account the fact that Medicare is a demonstrated extremely effective government program which does not interfere whatsoever with the physician-patient relationship and that the insurance industry has deprived Americans of basic health care rights by inserting itself into the physician-patient relationship in countless ways on a daily basis throughout the United States. Moreover, if the government really took "hands off" the life of its citizens, we would not have public schools, police departments, fire departments, roads, Medicare, Social Security, unemployment insurance, a minimum wage, worker's compensation, the armed forces, public sanitation and so on.

Sarah Palin is such an easy target that I am reluctant to use her as an example, but her reaction to the inclusions of certain language in the proposed bill inserted by a Republican congressman illustrates my point quite aptly. Before she quit her short tenure as Alaska’s governor, she endorsed a proclamation for the elderly to prepare living wills to guide end of life decisions regarding healthcare. The language in the health bill which allowed the elderly to do exactly that (by consulting with personal physicians) was characterized by her as “death squads.” Of course, some people who believe people like Palin who just make things up without factual bases were upset. Assessing the various reactions to her stupidity is where the rubber meets the road.

Don writes further, “My guess is we may have differing views on the proposed healthcare plan and whose behind the outrage . . .I also feel a very deep sense of loss regarding our elections process. It is now so expensive to run a campaign it wreaks of abuse and corruption. The money that flows into campaigns directly and indirectly from Unions, Special Interest Groups, and Corporations is staggering. Add that to the number of Lobbyists in Washington and it's no wonder constituents wonder just who their elected officials represent. I always go back to the old adage, the first thing a politician does when they get in office is start planning for re-election, and for most of them they can't do that without big bucks. This goes for Republicans as well as Democrats. Maybe that explains why the Republicans ran McCain. . . . In closing let me apologize for rambling on and on and like I said at the beginning all of this is not directed solely at your email and concerns, I just can't help myself. Got to go now because my head hurts.”

Don then signs off as “An Independent Voter,”

Don, let me say this to you directly. I share your sense of loss and my head hurts too. The realization at this stage of my life is that the ideals of our American way of life may be just words that are mouthed beyond which there is no real meaning bothers me greatly.

No comments: