“So, what do you think about health care reform?” asked Geoff. My wife’s family had gathered to celebrate my mother-in-law’s 80th birthday. I always looked forward to the food and the stimulating conversation, particularly with Geoff, my ‘liberal’ brother-in-law from New Hampshire. Being well read, Geoff loved a good debate on a variety of topics. But this topic had the potential to be long winded and personal. All I wanted was some of Mom-Mom’s brisket with her famous homemade barbecue sauce. I just stared at my plate, piled high with delicious food, knowing that the talk would be heating up as my food got cold.

The table was crowded with hungry family members. But Mom-Mom was sitting over in the corner with her leg propped up on a stool. After working all afternoon in the kitchen preparing the meal, her leg was predictably aching with severe pain. But she said nothing.

“It’s simple, yet complicated,” I dodged while diving into some hot mashed potatoes with butter and garlic.

“Simple?” countered Tim, my ‘conservative’ brother-in-law from Delaware. “One amendment was 500 pages. The only thing simple are the minds of the legislators who will be voting on it.” I continued staring at a table full of wonderful food knowing that we had just pried open a big can of worms.

“All we have to do,” he continued, “is figure out how to pay for 45 million more people using the same number of doctors, while spending less. Now that’s squeezing a fat lady into a size 6 girdle if I ever saw it.”

“All we have to do is to get doctors to quit ordering all those unnecessary tests and doing all those unnecessary surgeries,” Geoff said, enjoying the doctor jab. “Then we’ll have enough savings to treat everyone.” I winced each time he said ‘unnecessary’ because I knew that, to some degree, it was true. “The Dartmouth Study Group,” he continued, “studied the practice patterns of doctors all over the country. They found huge variations in the number of tests different doctors order, depending on where they live and practice.” Geoff loved to emphasize his connection to the Ivy League university in his hometown.

“That’s true,” I conceded. “Everybody orders unneeded tests from time to time. But there are a lot of reasons for that. Doctors aren’t just padding their pockets.” I thought of Mom-Mom sitting in the corner. She had been to numerous doctors over the years looking for relief from her leg pain. One orthopedist operated on her back. One neurologist had tried a whole list of medications. Nerve blocks, acupuncture, even massage therapy had failed to give her any relief from her pain.

“They do get paid by the insurance company for all those tests,” Geoff persisted.

“True, but sometimes patients demand those tests. If you sprained your ankle and came to the ER, you’d expect an X-ray, wouldn’t you? You wouldn’t be satisfied if I just examined you and sent you out.”

“And if you went to another doctor, which you would,” Geoff’s sister from Kentucky chimed in, “and he X-rayed you and found a tiny little crack,” – she said ‘tiny’ with a high squeaky voice – “you’d sue the first doctor for a million dollars.” The family seemed to mirror the nation in its divide over this issue, both in geography and emotion.
“Nobody is suing anybody,” said Mom-Mom in her warbly voice as she repositioned her leg on sthe stool. It was obvious that she was having a ‘bad day’ with her leg, but she wasn’t about to let it ruin the afternoon.

“I know you would never sue anybody,” I said, following Mom-Mom’s lead.
“Sometimes unnecessary tests are ordered because I don’t have access to the complete records of the patient. So tests get duplicated.” I was trying to take the conversation away from ‘unnecessary testing’ because I could see Mom-Mom taking the whole topic very personally. She never wanted to be a burden to anyone, let alone be the source of the national debt.

“Electronic medical records would help solve that,” I said, “but even that issue isn’t as simple as it seems. Electronic medical records can slow things down as often as they speed things up. There are huge privacy concerns. Geoff, would you want everyone to know that you had an STD?” Geoff’s wife, Sharon, and Mom-Mom both shot looks at Geoff.

“You’ve never had an STD, have you?” Mom-Mom asked.

“Of course not.” Geoff glared at me.

“Bad choice of examples. Sorry,” I said. “But you get what I mean. Plus if you have ever dealt with government computers, you know their systems are always cumbersome and hopelessly out of date. Computers go out of date every few years. Can you imagine the cost of updating all the government computers?”

“So you don’t think we should computerize medical records?”

“Of course we should. But don’t expect it to save us any money. It will cost more, not less. Same with preventive care. We should do it, but don’t expect it to result in savings. It will cost more.”

“Obama knows,” cracked Tim, “that the only way to pay for all this is to ration care for the elderly. He’s talking about saving $500 billion by making Medicare ‘more efficient’. That’s just another word for rationing.” I saw Mom-Mom wince as her sons squared off over the dinner table.

“So you think the government is going to set up ‘death panels’ to decide which elderly person lives or dies?” Geoff scoffed. “You’ve been listening to too much Rush Limbaugh.”

“If some board in Washington decides not to cover a procedure for elderly people just because they won’t contribute enough to society in their remaining years to pay back the cost, what’s the difference?” Tim said.

“You’re both right to some degree,” I said, feeling surprisingly agreeable. Their arguing had given me time to wolf down a few bites. “None of the proposed laws have ‘death panels’. But every law can have many unintended consequences. And most of our current expenditures are on the elderly. So if President Obama wants to keep this budget neutral, he’s going to have to get the money to pay for it somewhere. Just saying that we are going to make the system more efficient is disingenuous. If it was that simple, they would have done it years ago.” I forked my cooling brisket in the hopes that the conversation would die a natural death. I was ready for another topic of conversation. Then came the zinger.

“I read somewhere,” Sharon, Geoff’s wife, began, “that in Africa, when a person gets old and sick they will just go off into the jungle and sit under a tree until they die.” The table went silent. One side seemed to gaze off into the sunset with thoughts of a noble death in a peaceful setting while the other gasped at the thought of a helpless person being torn apart by hungry animals. Mom-Mom just sat in the corner, consumed by the throbbing pain in her leg.

Suddenly the lights went out and my wife entered the room with a cake ablaze with candles. “Happy birthday to you,” my wife sang. Reluctantly and discordantly, everyone joined in.

Mark Plaster, MD, is the executive editor of Emergency Physicians Monthly

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