The winds of hurricane Sandy have stopped blowing here in NYC but we now anticipate the winds of change that will surely rain down upon us on Election Day. I'm not going to choose the side of either Obama or Romney, especially since this election seems to be more about voting against the guy we don't like rather than really galvanizing behind one capable and confidence-inspiring candidate. Let's restrict this conversation to an issue near and dear to me and my patients - health care. And my apologies at the outset, this is about the problems. If I had a solution I would run for office or join a think tank, or write a book, or something.

The Problems:

We are a nation of 300 million people, and aging. Health care may or may not be an inalienable right, but as the land of the free it would be nice to imagine that every citizen is entitled to the same level of skilled, quality health care. But it is exceedingly difficult to deliver quality accessible care at a reasonable cost. Currently health care costs consume 17.9% of the GDP of the US, by far the highest percentage of any country in the world.

This country has the potential to deliver great health care. We have some of the best doctors, hospitals and research institutions in the world. A patient with good insurance and a savvy knowledge of the system can receive cutting edge treatment for just about any disease, common or rare. However delivering unlimited care to everyone, especially end of life care, and care of chronic and complex disease and trauma, is very expensive. Consider that the top 10% of medicare recipients by expenditure received 64% of the Medicare dollars in 2009.

And let's think about a few generic, but specific scenarios:

  • Grandma is 85, had multiple strokes, is in a vegetative state, and is now on a ventilator in an ICU with pneumonia and a urinary tract infection. The situation is dire, yet the idea of removing care is morally repugnant and the family wants all heroic measures as necessary.
  • A 42 year old father of 4 has metastatic colon cancer. His chance of survival is in the single digits. There is a new chemotherapy agent that will prolong his life by 3 months, but it costs $50,000 per month. Should that money be allocated to him? On the other hand, how can we as a country of bountiful wealth and opportunity say no? Or maybe his family should pay for the treatment out of pocket?
  • A 50 year old diabetic develops a foot ulcer. It becomes infected, and the infection spreads to the bone. He now needs a vascular surgeon to restore blood flow to the foot, and a podiatrist to amputate part of the foot, and reconstruct the remainder to allow him to walk. Or, he can undergo a below-knee amputation, a definitive procedure that will allow him to walk with a prosthetic limb and guarantee an infection will never develop in that leg again. Who decides whether he keeps his leg?

The solutions?

I wish. Is universal health care the answer? In England, everyone is covered, but accessibility is an issue and wait times for physicians and hospitals are far longer than here in America. In Israel, government sponsored health care is the norm, but many drugs and diagnostic tests are simply not covered. Our fee for service system rewards those who treat the sick, perform procedures and order many diagnostic tests. Doctors order unnecessary tests to guard against legal action. There are many hospitals, each of which requires many patients to maintain a profitable bottom line. Young physicians are compelled to enter specialties that are more lucrative in order to pay off an average of $250,000 in student loan debt. And a private health insurance system is mired in administrative costs and CEO bonuses.

Any solution is going to require sacrifice on the part of doctors, patients and hospitals. Tort reform, universal health care, student loan subsidies, and a reform of the health insurance industry are all potentially good starting points. One thing is for certain, our current system is unsustainable. Our country owes its citizens better, and we can formulate a workable solution for everyone, I think. If anyone has one, let me know, maybe I'll vote for you.

See you in the office.
Dr. Ernest L. Isaacson