This is a stream of consciousness post, so I’ll apologize in advance for rambling. As I read through the post, it jumps around a bit, but it really does get to a point … eventually.

I’ve resigned myself to the idea that our medical system is going to become “socialized”. People want change. Our medical system needs change. President Obama has already stated that we’re going to get change.

As I work my shifts in the emergency department, I see a rather perverse distribution of health care in this country. People who work all of their lives contributing to our economy have little or no access to medical care because it is too expensive and they cannot afford insurance premiums. They make too much money to be covered under Medicaid, they don’t have a disability to qualify for Medicare or disability insurance, and they are too young to meet Medicare’s age limits. In an emergency, the people who sustain our economy worry about how they will be able to pay all of the medical bills. Just being in the emergency department and knowing that soon they will receive a huge bill is as traumatic for them as their illness is. I will never forget about one patient complaint I read that said “As soon as I saw the bill for your services [meaning the hospital ED charges], I almost needed your services again.”

Meanwhile, I see many perfectly healthy people who do not work and who contribute little to the economy who are fully entitled to walk into an emergency department and receive millions of dollars in medical care. Expensive evaluation for coughs, runny noses, pregnancy tests, work excuses, prescriptions for Motrin (so it can be picked up a the pharmacy at no charge), sometimes even follow up care – all at no cost to them in the emergency department.

I dislike the idea of a “socialized” system, but I dislike even more the lack of access to medical care that occurs with so many working families solely because their situation isn’t deemed “dire” enough to receive government handouts.

So socialized medicine, you win. We must take care of our own better than we are doing so now.

Then I sit back and try to imagine how future medical care systems in this country will operate.

I mentioned previously that once socialized medicine arrives, we’ll have to change the way we think about medical care in this country. Here’s another article about how our values affect medical care. I foresee a system in which futile care won’t be provided unless the patient pays for it. I don’t think that’s a bad thing … except we have to come up with a definition for what care is and is not “futile.” It won’t stop there, though. A lot of expensive care will have to be rationed. If patients want expensive care, they’ll have to pay out of pocket for it. Cancer treatment will be limited. Kidney dialysis will probably also be limited. Advances in HIV treatment will be curtailed – if you want expensive medications that have only a small benefit in outcomes, you’ll need to pay the $12,000 per year out of your own pocket. Ditto for the MRI to find out what’s causing your shoulder pain – just go to a government physical therapy program instead.

One good thing about such a socialized system is that once the government stops paying for expensive testing and treatment, market forces will kick in. If there’s no demand for a service because of high prices and lack of government reimbursement, then the entity providing the service either maintains its high prices and caters to the rich few, goes out of business, or lowers its prices to sell more of its product to the masses at less of a profit. Walmart created billionaires with high volume and low prices, not high profit margins.

A socialized medical system will also restructure the insurance industry. Who’s going to want to pay $1000+ per month for insurance to cover routine medical care when you can get routine medical care for free? Maybe boutique practices will become more common – there patients can pay cash for routine medical care rather than endure the wait for free medical care. Cash-only practices will also give patients a greater chance of maintaining their anonymity if they so choose.
Those who want insurance can purchase it so that they have faster access to major surgeries or more access to specialist care. Everyone will get all their care for free, but in the “fast care, quality care, free care” paradigm, people should be able to purchase a right to faster and higher quality care.

Socialized medicine will inevitably bring up new inequalities and new issues. There will be a fundamental unfairness in access to medical care that is not unlike the system we have now – only in the next iteration, everyone will have the same access to some level of government-sponsored medical care … the care will just be time-rationed. The focus of people’s angst will be on the speed at which those with insurance can access their care while those without insurance are forced to wait.
Civil rights groups will complain, but just as with every other private industry in this country, there is not and should never be an entitlement to the best of any product, whether it is luxury dining, luxury autos, luxury housing, or luxury medical care.

I also think that there will be another shift in focus – one that gives me hope, but that also concerns me.

Doctors and hospitals will no longer play the “bad guy” role. Instead, in almost every scenario, the government will take over the role as the “evil villain” that limits care. If a socialized system will pay hospitals and doctors for everyone’s care, providers will have no incentive to limit testing or treatment. Similarly, if patients are getting the care for free, the patients have no incentive to limit their demands. That leaves the government as the source of cost-containment. No longer will patients become outraged at hospitals and doctors. Instead, patients and the healthcare providers will fight the uncaring government.
As in …
The government wouldn’t pay for treatment and let him die.
The government says that the treatment “isn’t supported by evidence.”
The government “couldn’t afford” a costly cancer medication.

My guess is that the system will pit patients and doctors versus the government bureaucracy. Hopefully doctors and patients will be able to work together more as a team.

“Us” against “them”.

When you think about it, though, just like the identical twins in the picture, “us” and “them” are pretty much the same people. “We” will be fighting against a government comprised of “us” who are there to protect “our” interests.

Who really is the “them” part of this equation, then?

Those who use the most medical resources. The chronically ill. Those with severe illnesses.

All that separates “us” from “them” is a serious medical illness.

This is where “we” have to be very careful in designing a medical system for all of “us.”

Those in the “us” camp want to limit payouts from the system – keeping money away from those sickly “them” people who are disproportionately using the system resources.

The care that “we” agree to provide to “them” now will be the same care that “we” receive if we become one of “them” in the future.

Just how well will “our” new system take care of “them”?

That concerns me.