The New York Times reported on 2-19-10 that virtually every state is making or planning significant cuts in Medicaid benefits.¹ These actions are taking place while demand for Medicaid grows. This entitlement, originally conceived as a support for those in lower socioeconomic classes and disabled persons, now is a necessary lifeline for those formerly in middle income groups who have lost their jobs. Medicaid enrollment soared by 7.5% from June 2008 to June 2009 (3.3 million new enrollees). The 2009–2010 increase is expected to be even larger.

The American health care crisis is not a doomsday scenario concocted by shrill socialist Chicken Littles. State governments can’t afford to pay their health care bills. It’s not surprising that individual Americans can’t afford to pay for health insurance and are dropping coverage by the millions.

The Medicaid news is the canary in the coal mine. When the canary dies, it’s time to pack up your gear and get out. In terms of health care, the demise of Medicaid is the clearest possible signal that the entire edifice is about to come crashing down.

States can’t pay Medicaid bills. Hospitals and physicians will lose substantial revenues. Many hospitals will file for bankruptcy. Others will drastically reduce services, starting with community assistance programs. Physicians will discontinue participation in Medicaid in frantic attempts to regain financial solvency. In the worst case, hospitals and physicians will only accept new patients on the basis of proof of ability to pay. Health care policy in American will become “no cash, no care”. Tens of millions of Americans will have zero access to quality medical services.

We’re veering sharply in the direction of a society of medical haves and have-nots in which there is no middle ground, no available safety net. Public health disasters will rapidly befall such a society, disasters that will not spare those fortunate enough to have “good benefits”. As millions of Americans, particularly low-income children, become less well, they will become breeding grounds for bacteria, viruses, and parasites. The deadly diseases of the past — tuberculosis, diphtheria, and whooping cough — will return with great force.

New infections will arise as a weakened population makes it easier for microorganisms to take hold. Diseases with the pathogenicity of HIV will race through communities and cities, spreading from region to region. Neither Republicans nor Democrats, neither Red states nor Blue states, will be spared from this public health implosion.

American was formerly the land of opportunity. Thanks to congressional obstructionism and the national mood of me-firstism, American will soon be the land of opportunistic infections.

¹Sack K, Pear R: States consider Medicaid cuts as use grows. The New York Times, 2-19-10, p 1, column 1

Revising the doctorpatient relationship is a very important conversation. It is worthwhile and instructive to first look at how the media — broadcast, print, and web sources — participate in and affect this relationship. Stating the obvious, there are good media and bad media. Mostly bad. The power and necessity of the 24-hour news churn forces all broadcast news stations to put out all kinds of junk. The most sensational stories attract the most eyeballs. The news cycle affects newspapers as well.

The prime exception to this race to the bottom is The New York Times. Not that everything the Times prints is the unvarnished, untainted truth. But the Times does intend to provide the news. The Times is not tabloid journalism, as almost everything else seems to be.

Articles in The New York Times on science in general and medicine in particular are uniformly excellent and written with as much objectivity as possible. But the vast majority of media outlets focus on what sells, i.e., the worst aspects of human behavior. Whatever can be construed as bad and wrong becomes the hot news of the moment.

The media intentionally — or out of ignorance — distorts scientific information. Overall the media has no conception of the process of science. Media needs blacks and whites. Science and medicine are neither of these. So, probably more than 90% of the “news” people receive on medical issues is tainted, distorted, and inaccurate.

People need to participate in medical decision-making. In today’s medical environment, it is shocking and appalling how much responsibility the patient’s family needs to take on in making critical decisions. What’s called for ongoingly, now, is a doctor-patient partnership. But patients and their families are poorly equipped to be partners with their doctors, owing to the very poor quality of medical and scientific information they receive from their media sources.

Physicians’ recommendations need to be questioned closely. Overall, physicians’ expertise has deteriorated significantly in the last 20 years. There is much too much fragmentation, too much taking-for-granted of benefits of high-tech procedures, and too much promotion of pharmaceuticals.

Of course, there are many more issues. But physicians with less than 20 years of experience — and that is most of them, now — are in a box. They have as much stress as do their patients.

So, patients and their families need to be smart health care consumers. The very important question is how to become an educated advocate. Many problems arise owing to peoples’ naive approach when they interact with medicine. Their knowledge base is pathetically poor. This is partly due to the ongoing deterioration of our educational system and partly due to the ongoing deterioration of the quality of the media.

We’ve reached a crossroads in our society where many Americans are just plain ignorant. They don’t need to be, of course, but the “dumb and dumber” mode has much attraction. When people haven’t exercised their brains in a long time, the place to start is not in a medical decision-making process. But shared decision-making by the patient, the family, and the doctor is now a critical necessity. Americans need to find ways to gain access to real information and educate themselves on the important issues of health and health care.

The free market has not fared well in recent years. Adam Smith’s “invisible hand” has had its thumb on the scales for a very long time. In the last 75 years U.S. markets have been free only in the sense that businesses are free to seek as much government protection as they believe necessary.

Agricultural markets are a typical example. Prices of corn and wheat have been heavily subsidized by the federal government for generations. Taxpayer monies prop up these sectors. Without government support prices would plummet to their natural levels.

The financial sector is a glaring testament to the infinite ways in which greed and corruption can distort the workings of a presumably free market. If finance was forced to return to “free” practices the big players would lose all their “free” money. Paradoxically, heavy regulation of the financial sector is now necessary to restore the mechanisms of a free market.

Similarly, the health care market as we know it is not “free”. Supply and demand factors are not applicable to health care. Supply of services is necessarily limited – these resources are not infinitely available. Demand is always 100% – demand is not able to fluctuate. A consumer may put off purchasing a new car for many reasons. But she cannot delay a life-saving medical service.

An obvious example of the severe distortions in the health care market is the vast numbers of people who currently postpone needed medical services. Another example is the fact that premiums rise annually at a rate of 10% or more. This could not occur in a supply-and-demand market.

So, the health care market never was free. Health care is a right and delivery of health care services needs government regulation. For-profit medicine is a non sequitur. Current markets cannot be “encouraged” to change. Medicare Part D provides an example of the extreme failure of such attempts at encouragement. Following institution of Medicare Part D, senior citizens found themselves paying significantly more for medications.

The New York Times recently reported on the acute run-up of prices for medications. Pharma – true to its rapacious raison d’etre – has increased prices at a rate not seen since 1992 – the last time health care reform was seriously considered. The interest of pharma is to earn profits. The business of pharmaceutical companies involves health care products. Their business is not health care itself. Likewise health insurance companies – their business is to earn profits. Government attempts to provide incentive and rewards will only result in the creation of end-arounds by these entities. We’ve experienced the end-stages of such hidden practices in the current severe recession.

Government incentives and rewards create market distortions in the majority of cases. The health care “market” has failed. As health care is not a free market, government regulation of health care delivery is required.

The optimal form of government regulation involves establishing universal health care. The United Kingdom, Australia, Canada, the Netherlands, France, and Switzerland have successfully implemented various forms of national health care. The U.S. does not need to reinvent the wheel. We can adopt any of these or utilize a suite of components. It is possible for the private sector to continue to offer health insurance, as is the case in the Netherlands.

There is no good reason for the U.S. private health insurance industry to exist. Medicare is widely acknowledged to be a successful system, warts and all. Extending Medicare coverage to all Americans is one possible solution to meeting our nation’s the health care needs.

It’s important to acknowledge that Medicare expenditures continue to rise at an inflationary rate. Many improvements are necessary to begin to control costs. One method would involve sophisticated statistical analysis of utilization patterns and attempt to remediate the treatment patterns of the outliers. Another is to significantly reduce utilization of the most costly diagnostic procedures and interventions. Recent reports on the effectiveness of mammography and cervical cancer screening are germane to these considerations.

The most important revision to our current non-system is to graduate many more primary care physicians. The federal government can provide inducements in the form of tuition relief as well as financial enhancements to establish practices in underserved rural locations and inner cities. Studies consistently demonstrate that increased numbers of family physicians directly correlates to reduced health care expenditures.

Current legislation before Congress is not the final solution. It represents a very good beginning and deserves our support.

Former President George W. Bush blithely asserted to a national (virtually global) audience that the U.S. already has universal health care — “all they have to do is go to the emergency room”. Bush unwittingly demonstrated his unconscionable ignorance of health care imperatives and basic economic principles.

The cost of emergency department (ED) services is several multiples of costs in physician offices. In U.S. inner cities the ED is the “doctor’s office”. Uninsured persons typically don’t have a family physician. Child care medical needs as well as daily incidents – best handled in a family physician’s office — are cared for by the ED staff — the doctor surrogates in these communities.

Also, uninsured persons typically postpone doctor visits until the problem can no longer be tolerated. They are sicker when they are finally evaluated and the services needed are more extensive. When these services are performed in the ED the total fees are significantly higher.

American society as a whole pays an ongoing hidden tax to support these unpaid ED fees. Costs to those who have the ability to pay are increased across the board. Employers, employees, and self-employed persons pay much higher annual health care fees owing to this single factor.

ED services deteriorate as well as a consequence of overutilization. ED’s are typically understaffed and undersupplied. Emergency departments are designed for emergencies. ED usage for non-emergent services is inefficient and inappropriate, causing services to deteriorate across the board. The result is a distortion of the mission of the emergency department and ineffective delivery of services to those who need care the most.

In addition, the mission of ED staff is to stabilize the patient. Ongoing care and prophylaxis are not part of the ED mission. The standard of ED care is to refer patients back to their family physicians. But uninsured patients do not have such a resource.

Non-emergent usage of the ED — a significant problem in itself — is the effect of the underlying lack of effective health coverage. Universal health care would restore balance to ED utilization and the economic benefits would be experienced by our entire society.

Although the ranters rant that those without health care insurance should “get a job”, investigating the facts tells a different story. But in early 21st century America, facts are easily swept aside as mere inconvenience.

Who needs facts when we have opinions? Blather, posturing, speciousness, and irresponsible inanities are the coin of our public discourse.

A few Americans do inquire as to the state of the facts. A substantial proportion of the 47+ million uninsured Americans are employed. And many millions more of those who do have health insurance have less than satisfactory coverage. Cost-shifting has burdened Americans with high annual deductibles and exorbitant co-payments.

A 35-year-old father of two develops a sudden, intense headache. His plan carries a $5000 annual deductible and he knows he can’t afford the $1200 price tag of an MRI of his brain. Three days later he dies of a ruptured intracranial aneurysm. Similar scenarios occur weekly across the country.

In the UK, Canada, France, the Netherlands, and other developed nations there are no such things as underinsurance or lack of coverage. Health care is a right. The U.S. stands alone in its ignominy.

Universal health care is a simple policy solution. Of course, the implementation is complex, but it’s not so complex that it can’t get done. We don’t have to reinvent the wheel. Any European nation’s policies can provide a working blueprint. The will to solve the complexities of universal health care is what’s required. At present in the U.S., irresponsibility rules the day.

We need a vision and a mission that are accepted by the majority of citizens and congressional elected officials. One vision states “every person will have timely and affordable access to needed health care services”. This should not be astonishing, but in America we couldn’t be further from this simple vision.

The costs of our delusions are extensive, formidable, and insidious. Each of us pays a steep penalty for indulgence of our current non-system of non-care. The direct costs are fairly obvious. The indirect costs are even more detrimental to our national welfare and well-being. The purpose of our American government is to provide opportunity to all citizens, to provide the circumstances by which each can flourish and prosper.

Those without health care are at a serious disadvantage in the game of life. At present America is failing miserably.

As we’re all aware, the U.S. is the only developed nation that does not provide its citizens with some form of universal health care. Are we special, or are we stupid?

We’re certainly not special. Former President George W. Bush enjoyed proclaiming that we have “the best medical care in the world”, but he notoriously never met a fact he could understand. The U.S. is near the bottom of the rankings for two critical measures of a nation’s overall health – infant mortality and longevity. And we’re near the bottom for many more health care parameters.

Yes, the U.S. has the most technologically advanced medical care. But as the Dartmouth Institute study - Health Care Spending, Quality, and Outcomes – showed with crystalline clarity, more is most decidedly not better.

So are we stupid? Yes, and what’s worse we’re blindingly selfish. The lead article in the 11-16-09 New York Times is titled Drug Companies Increase Prices in Face of Change. This year’s pharma fees are described as representing the “highest annual rate of inflation for drug prices since 1992″.

Pharma, never known for being shy when it comes to grabbing money, is merely following the notorious example of U.S. financial institutions. Having been propped up by citizen taxes, these desperadoes have awarded themselves $30 billion in bonuses for 2009.

Back to stupidity. According to a 2007 survey conducted by The Pew Research Center, 50% of respondents failed a 23-question general knowledge exam. Sarah Palin’s sound bite on “death panels” was believed by millions. At this point, most  Americans are not smarter than a fifth grader. Understanding the imperatives of universal health care as well as the economic losses of our current non-system is beyond the grasp of many tens of millions of Americans.

In such a climate, how can universal health care possibly take root?

Many Americans decry “socialized medicine”. They do not realize the U.S. non-system is already has significant “socialization”. American citizens subsidize tax-deductible employer health benefits as well as the emergency department utilization of the 47+ million uninsured. Our tax dollars pay for tax-deductible health benefits of others and our high insurance premiums and out-of-pocket costs subsidize emergency department accounts receivable.

All Americans pay a significant ongoing hidden tax representing loss of productivity and loss of quality of life of the 47+ million uninsured. These individuals are less healthy. Their productivity and contributions to society are constrained. Our total resources are drained proportionately. These are subtle distinctions which are lost on many Americans.

But economics are only part of the discussion. Common human decency could be the paramount consideration. However, America daily becomes more fossilized in its me-ness. And me-ness becomes mean-ness with no effort at all. “Me first” is becoming the national slogan, blaring from the Senate and House of Representatives floors and bleating from the smug, self-righteous proclamations of finance CEOs and directors.

Democracy without humanity easily degrades into tyranny. The tyranny of the majority.

Health care is a right. The polity of every other developed country recognizes this. Universal health care is necessary in the U.S.