Health care reform, revisited

A senior medical student clerkship is emergency medicine, and for orientation we had a series of lectures. In one of them, the doc described a tragic case that took place in 1988. There was a migrant worker in Texas who had classic symptoms of meningitis. However, at each hospital the ambulance was turned away because the patient had no health insurance. Ultimately, the patient ended up at U-Texas Southwestern but ended up dying due to the costly delay in treatment. Meningitis is an extremely dangerous condition but is very treatable with the proper antibiotics.

A 60 minutes special exposed the recorded conversations between the ambulance and the hospitals that one after another inquired about the patient's health insurance status before turning the patient away. This led to congressional legislation which dictated that emergency rooms must treat patients regardless of insurance status. In effect, the bill gave all Americans the right to a medical exam and treatment regardless of ability to pay. This mandate was, perhaps not surprisingly, unfunded by the federal government. Almost half of ER patients have no health insurance. Given that (most) hospitals must turn a profit, the 1988 unfunded federal mandate ends up being paid for by patients with health insurance.

To me, the individual mandate of the Obama health care bill stems logically from this 1988 bill. In other words, if the individual mandate is unconstitutional, why isn't the 1988 bill unconstitutional? Republicans are trying to argue that you can't force people to buy something (health insurance). But the 1988 bill did something worse - it forces people to buy something for someone else! We can talk about personal responsibility until we are blue in the face, but at the end of the day, we as a society are not willing to not treat sick patients. That is a good thing, but someone still has to pay for that treatment. Right now, only hospitals and people with insurance are paying. With an individual mandate, even though low income citizens will require help, everyone will have some role in paying for their health insurance.

While Republicans want to repeal the ACA, they are quick to point out that they favor certain parts of the bill - for example, people should not be denied insurance based on pre-existing condition. Tell me though: If I cannot be denied coverage based on pre-existing condition, why would I ever buy health insurance? Why not just wait to see if I get sick, and only buy insurance if I do? If everyone did that, the insurance market would collapse spectacularly. The only way to prevent gaming of the system like that is an individual mandate: you cannot do one without the other.

The ACA deals with access to health care, but the real problem in this country is delivery of health care, which is often expensive and inefficient. If we are to secure the fiscal future of our nation, we need to address these serious challenges - and quickly. More health care reform is needed, not less. Repeal is out of the question, and attempts at such are just posturing. Obama should tell Republicans that if they have a better bill that they want to replace the ACA with, if they have modifications, or additions, he is all ears. Obama should challenge Republicans to put up or shut up.