So You Don’t Like Obamacare?

So you don’t like Obamacare?  Too expensive, you say. We just can’t afford it. Too much like socialized medicine.  Your co-pays are higher. Why should your insurance be more expensive just to help pay for others to have medical care?  After all, in our country, we expect people to take care of themselves. If they can’t, it’s their fault. Right?

Let’s think about the implications of that philosophy. If an adult fails to provide for his or her family adequately and is unable to afford health insurance, who pays the price? The children pay the immediate price, and we, society, pay the long-term price.  What happens when children don’t get adequate medical care? It impairs their ability to perform in school. Where does that lead? To dropping out of school, having fewer opportunities as far as jobs, decreased ability to support their own families, etc. You can see the consequences of that.  The extreme outcome is alienation from society and perhaps criminal activity. That definitely affects society as a whole.

What happens if parents of children don’t’ get adequate medical care? They can’t focus on the job of being good parents. That affects society as a whole.

We pride ourselves on our technical advances in medicine. We tend to think that leads to good medical care. But consider this.  Christopher Ingraham wrote an excellent article for the workblog of the online Washington Post in September of 2014 titled “Our infant mortality rate is a national embarrassment.”  The CDC (Center for Disease Control) had issued a recent report indicating that the infant mortality rate for the US was 6.1. This means that for every 1000 live births, there are 6.1 deaths.  Compare that with the infant mortality rates of Finland and Japan at 2.3, of Korea (yes Korea) and Spain at 3.2 and Switzerland, Netherlands, Ireland, and Greece at 3.8. We are # 27 in the rankings, definitely not #1. So that suggests that all of our technology is not benefitting certain segments of society.

Ingraham quotes from a draft paper by Chen, Oster, and Williams, which was later published in 2016 in the American Economics Association Journal of Economic Policy. There may be some differences in how pre-terms births are classified in other countries, for example whether a pre-term birth before 20 weeks is considered a miscarriage rather than a stillbirth. That may account for some of what seems like a surprisingly high infant mortality rate, but it doesn’t account for the entire picture.

The most interesting point of the Chen paper is that the infant mortality rate actually increases when you consider the post neonatal period, the time between birth and 12 months.  The infant mortality rate gap actually widens between the US and other wealthy countries during this period. The authors conclude that this is due to socioeconomic disparities in our country, in other words the higher post neonatal mortality rates are coming from disadvantaged groups.   Certain states actually have an infant mortality rate higher than some 3rd world countries, for example Alabama with an infant mortality rate of 8.7 per 1000 live births and Mississippi with a rate of 9.6.

So does Obamacare fix this? Will the post neonatal infant mortality rate go down now that more people have access to medical care? Possibly, but it’s too early to tell.  The Affordable Care Act has not been in place long enough to measure the impact on infant mortality, but it is a start.  The infant mortality rate certainly won’t go down without some intervention, and there had not been any significant move to make medical care available to those without insurance before the ACA was passed. There was Medicaid, but many people below the poverty line did not qualify for Medicaid particularly in states with very stringent requirements.

Do we care about the infant mortality rate? It probably doesn’t directly affect our day-to-day lives. But what are our values and ideals as individuals and as a country? Do we leave the disadvantaged behind and suffer the consequences as a society?  I just don’t think that’s compatible with who we are.

I’m glad to see that medical care is more accessible.  However, having access to care is not enough. It has to be good care equal to the care that the rest of us have. If it means that my insurance is more expensive or the co-pays are higher, then so be it.

We are one of the wealthiest societies in the world. Does that benefit trickle down to people who are poor? Are we isolationists in our own society, not caring about the welfare of others, or do we try to elevate the living standard of society as a whole? Certainly having access to affordable medical care doesn’t guarantee that people will take advantage of it. People still have the opportunity to make good or bad choices in life, choices that affect their lives, their children’s lives and our lives as members of society.  But healthy people generally think more clearly and are more likely to make good choices. That can make life better for all of us.


Patienthood vs. Personhood

For too long in the medical profession, we have referred to patients as “the diabetic” or “the schizophrenic” or “the addict” or “the bipolar.” Most physicians would say that this is just shorthand; we know that our patients are people. However, I believe that we need to apologize to all patients for this terminology. It dehumanizes. People are not defined by their illness. You are a person with diabetes or a person with schizophrenia, or a person struggling with addiction or bipolar disorder. Sometimes I think you, the patient, actually come to believe that the diagnostic label defines you. You begin to think of yourself as a schizophrenic before you think of yourself as a wife, husband, mother, teacher, friend, sister.  We in the medical profession need to stop this pigeonholing of our patients and you, patients, need to stop buying into it.

I sometimes wonder if this is primarily occurring because of the push to see more patients. As busy physicians, we have to focus on the problem at hand. Those of us who are employed usually have a target amount that we are supposed to bill each month.  That means seeing a certain number of patients each day. Those in private practice have overhead and malpractice premiums.  Some physicians see the electronic medical record as a barrier between patient and doctor. Patients may feel that the doctor spends more time looking at the computer than at them.  We are very focused on technology. Even in psychiatry, this is happening to some extent. But is that really an excuse?

My grandfather was a country doctor in a small town in Kentucky. I didn’t know him. He died before I was born. I grew up in the same small town. Many people told me how much my grandfather meant to them. He made house calls. He delivered babies at home. He saw his patients on their turf, not necessarily on his. I’m not saying that modern technology is bad, because the survival rate for babies and all patients is so much better now. But you can be sure that he knew his patients as people. He visited their homes, he saw them at their worst and at their best.  He treated their grandparents, parents, and children. There is something good about that. I don’t know how we can replicate that today.

When I wrote the required essay on my application for medical school, I remember writing that I thought medicine was the perfect bridge between science and art. We’ve tilted toward the science side, and that certainly has its benefits. We are saving more lives. We have a better understanding of why and how our treatments work. But I hope we don’t lose the art side of medicine.

So stand up for your personhood. Remind us, when we forget, that you are a person with a life above and beyond your diagnosis.  Remind yourselves that there is more to life than your illness, that you are members of a community, country, world and universe bigger than your illness.   Don’t get me wrong, I love the science of medicine.  We have made huge strides in the treatment of cancer, heart disease, mental illness and so many other diseases.  I love the black and whiteness of science. I love the certainty of science, though I sometimes wonder if that really exists. But I feel that we may have lost some creativity and humanity in the face of the explosion of technology.   When I end my career as a psychiatrist, I hope that I can say that I practiced the ART of medicine.