Sunday, December 06, 2009

Health care reform: The horse and the cart (By Skylanda)

There is an undercurrent to the current health care reform debate – a sneaking undercurrent of suspicion – that wonders if this nation can successfully insure every American when the health infrastructure does not exist to take care of every one of those individuals. Primarily among the deficits in the medical workforce are loci of primary care: family doctors, general internists, pediatricians, and mid-level providers like nurse practitioners and physician assistants who can effectively and efficiently take up the slack for busy offices.

This suspicion is not a paranoid fantasy. It is real, and the rush of patients into primary care if we did insure the 45 million currently uninsured Americans at large would put a rather onerous stress on clinics and providers currently in practice. The Washington Post ran a story this week on this very phenomenon, highlighting a small-town country doc in rural Texas whose bursting-at-the-seams solo practice would nearly double if the uninsured portion of the town (Texas has the highest uninsured rate in the nation) were to suddenly have paid access to his services.
"The system's going to be overwhelmed when everybody's insured," he says. "We're putting the cart before the horse. You've got your little insurance card and there's no doctor to show it to -- or you have to wait eight weeks to see one."
So this is the answer then: wait a generation or two until there are enough doctors for everyone, and then offer out insurance to the masses. Until then, understand that we can only service the lucky fraction that does have insurance, and hell with the rest. Yes?

No. This approach to the uninsured is a folksy-sounding, down-home, home-grown excuse for basic, unconscionable injustice. If we put the horse of sufficient providers ahead of the cart of health care reform, we are done for. Without the demand, primary care will continue to be considered the relatively low-paid, overworked dustbin of medical practices – the current circumstance that drives most medical school graduates to pick cushier practices like dermatology, anesthesiology, or the medical subspecialties. In the meanwhile, a growing number of uninsured Americans will be unable to access not only primary care, but also coverage for emergency care if needed. Overwhelmed primary care clinics will have to put the brakes on their own patient panels when they reach capacity – regardless of how many are clamoring at the door – until demand does it’s job in upping supply of providers. Keeping an underclass of uninsured patients around just to do the dirty work of deciding who gets priority in to see a busy provider in a small town is a cop-out of Herculean proportions: patients deserve insurance whether or not they have primary care access, because primary care is not the only measure of security that insurance provides.

It doesn’t matter which you label the “horse” or the “cart”: provider availability or insurance access. Whichever way it goes, one has to start moving, and dragging the other with it. If the horse can’t drag the cart, then the cart needs to give the horse a good strong shove. Leaving so many individuals uninsured simply means leaving the whole apparatus mired in a mud trap until neither is any longer viable. The horse and the cart have been stalled out for too long; it’s time to start flogging the both of them.

Cross-posted from my infrequently updated blog, Loose Chicks Sink Ships.