Wednesday, January 21, 2009

Day One

Yesterday, I was one of the two million or so people who gathered in downtown Washington to witness the inauguration of President Barack Obama. Or, more accurately, I tried to.

On television, the inauguration was a grand spectacle, worthy of the occasion. On the streets of Washington it was a different story. Would-be viewers of the swearing in were required to enter the National Mall through one of about a half dozen security check points, which quickly became overwhelmed. One DC cop told me that "absolute chaos" ensued as the Secret Service closed checkpoints, with thousands still waiting in line, without informing local authorities. By the time President Obama was sworn a little after noon, many of those waiting found themselves on the outside looking in. I was one of them - after hours of trying and failing to access the Mall I ended up rushing to catch it on my office TV.

I relate my experience not in the spirit of whining about what was a truly moving and historic occasion. I was still glad I was there. That things didn't go smoothly is not at all surprising, given that Washington had never before handled an event of this size and the circumstances demanded extraordinary security.

I offer it instead, as a metaphorical and cautionary tale for the new President. President Obama takes office at a time when the demand for help from the government could outstrip its capacity to deliver, just as the demand from millions to watch the swearing in exceeded the government's ability to accommodate them.

This may especially be true of health care. The demand is overwhelming. The recession will cause millions of Americans to join the already bloated ranks of the uninsured. State governments are pleading for help from Washington for funds to keep their Medicaid programs afloat. Employers want help paying their employees' premiums. Will the Obama administration have the capacity to organize a federal response sufficient to meet the demand? And with a trillion dollar deficit, will it have the wallet needed to deliver on its will to reform health care?

Obama isn't dissuaded. In yesterday's inaugural address, he had this to say:

"The question we ask today is not whether our government is too big or too small, but whether it works, whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified ...

We will restore science to its rightful place and wield technology's wonders to raise health care's quality and lower its costs ... All this we can do. And all this we will do."

I was struck by the words he chose - helping families get the care they can afford, using technology to raise health care and lower costs. And by the words he did not say. No mention of universal coverage or health care for all.

Now, I still believe that President Obama is committed to covering everyone. After all, people without health insurance coverage are the least likely to have "care they can afford." But his choice of words also says to me that controlling health care costs will be a focus of his administration.

As hard it is may be to get agreement on how to extend health insurance coverage to everyone, controlling the cost of care will be an even bigger challenge. Experts tell us that as much as $700 billion is wasted each year on unnecessary or inefficient care. But that "waste" and "inefficiency" represents someone else's income, hospital bed, MRI, or profit from sales of drugs and medical devices. Getting control over that will test the capacity of our new President to bring about the change we need.

Today's questions: Do you think President Obama will be able to deliver on his promise to control health care costs and provide everyone with care they can afford? How will you help?


Jay Larson MD said...

President Obama will have stiff opposition to reduce health care costs. Insurance companies will want to keep their steep administrative expenses for their CEOs, pharmaceutical companies will want to keep their profit margins for their investors, hospitals will want to keep their income to build more and buy the newest MRI in town, and physicians will want to do more procedures at a higher cost.

In regards to the $700 billion of annual waste on unnecessary or inefficient care, who defines waste and what study has been done to confirm that something done was wasteful? A large part of being a physician is to alleviate anxiety about medical conditions. Several times a test will be done to exclude a diagnosis that the patient is fearful about. I call these tests therapeutic diagnositic tests. Is the relief of knowing that the severe headaches are not due to a brain tumor wasteful?

As far as my contribution to keeping health care costs down...I will try to put up with all the manure and stay in practice as a general internist as long as possible.

Steve Lucas said...

This task will be extremely difficult as the entrenched interest have already started with op-ed pieces in major newspaper decrying any changes in a system that is very profitable to a select few. Simply put, we cannot afford six figure treatment for a comatose patient, already in the ICU, with the goal of extending life for a week.

We as patients need to not be lulled into a false sense of security that repeated office visits and testing will lead to good health, but rely on changing life styles and asking those difficult questions, such as: Is this necessary?

Collectively we need to lobby for policy changes to minimize health cost and prevent institutionalized mandates that serve no purpose. One example is the FAA's Third Class Medical. This covers private pilots flying personal aircraft. At the end of the Clinton Administration the FAA, along with the various pilot organizations, agreed there was no scientific evidence that this requirement fulfilled any safety need and was to be eliminated in favor of a drivers licensee requirement. The AMA lobbied to continue this requirement based on financial need, not for medical or scientific reasons.

This has lead to an institutionalized cost and a convoluted system of regulations that does not improve safety for the pilot or public. (Disclaimer, I am a private pilot and aircraft owner.)

Jointly, doctors and patients, need to work towards a system that allows more time for interaction to determine the proper use of technology and medication. Blanket testing of entire populations only leads to additional testing, and often misunderstanding of results. These issues will only be overcome with time.

Steve Lucas