EDMOND — It would be a relief to hear all the newspersons talking about something other than the economy, except that now they’re all talking about health care reform, which is likely to be an even bigger conundrum. Nevertheless, we must talk about it before we can do it.

Oddly, there are still some folks who think it’s all just fine the way it is. They either have no understanding at all of its importance, or have never had to do without it, and apparently feel that access to health care should be the privilege of those who can already afford it. Fortunately, those folks are in the minority, and that’s at least a start.

People who understand the urgency of reform probably know that the lack of access to health care insurance by 48 million people is a severe drag on our economy and, even if they have no social conscience at all, want to correct the situation. Fortunately, most people now feel that access to health care is a right, and that should be helpful, especially if that view prevails in Congress.

It now appears that Congress is poised to enact some type of health-care reform. But the devil is in the details, and they are many: How it is to be paid for, how will the various parties share in that burden, what are the essentials of a reformed system, how much is voluntary and how much is mandated, how much is private, how much is governmental. All these matters and more will be hashed out in the coming months (assuming that we really get it done this year) and we will have some type of legislation. Most of us, I think, will want it to cover most if not all people who are not currently covered, and in a form that covers at least basic needs, at a reasonable cost.

Now some more tough questions come up: What does basic mean? How much cost is too much? These must be answered from more than just the perspective of budgets and deficits. They must include consideration of the measures of health status, people’s attitudes about personal health care, essentials versus frills, personal versus public responsibility. Congress must address these questions ideologically and practically. However it turns out, the process must continue, so that what is ultimately legislated will approximate the way John Q. and Jane Q. Citizen answer the questions, each from his or her individual perspective.

I have two perspectives that form my answers; one, as a “consumer” for 70 years, the other as a “provider” for 37 years. About half of my time was with the medically underserved and unserved. The other half encompassed a broad range socioeconomically. All but three years was in Oklahoma. It included the settings of private practice, the Department of Veterans Affairs, the U.S. Army, the OU Medical Center, and charity care. So I have seen up close how people’s lives and attitudes are affected by both deprivation and affluence.

Through the years, I observed three basic attitudes about medical care, closely conforming to three systems of care. These are (admittedly in oversimplified terms): 1) lifeline, 2) entitlement, 3) commodity. They generally characterize, respectively, l) the charity patient, 2) the VA, Medicare, or Medicaid patient, 3) the “private” patient.

To the charity patient, the really dirt-poor, a visit to receive medical care was often a matter of week to week survival, as in the severe diabetic or heart failure patient. Sometimes it also was the chance to just talk to someone who cared. To the VA, Medicare or Medicaid patient, visits were the opportunity to get treatment for chronic illnesses and, at the same time, a visit with old friends with similar problems. I would point out that with few exceptions, patients in this group were no more demanding than those in the other groups.

The visit for the private patient (who might also be on Medicare) was usually more focussed on efficiency or choices. Sometimes it was also to “shop” for a diagnosis or a more appealing treatment plan, or to request a specific medication for a self-made diagnosis. This is the commodity view in the extreme, like buying a new dishwasher on the basis of the best deal. It is, at least in part, the commodity view that leads to overtreatment and its higher costs, along with the fact that current reimbursement formulas reward the performance of more procedures rather than evidence-based interventions.

Consumers of medical care, like everyone else, have their own ideological views. It is a favorite pastime among conspiracy theorists to grumble about “government control” or “socialized medicine” (without knowing what that really is), and then call forth the bogeyman of “rationing.” This meshes conveniently with another time-honored shibboleth, that “the gummint” messes up everything and that private enterprise always does everything better. Facts can inconveniently intrude on these comfortable myths.

The government (federal or state) is now involved in the administration of 60 percent of health care in this country, and the place it is least likely to be involved is in direct patient care. I saw a lot more interference in patient care from for-profit insurance companies than from any government program. So the political blather about the government getting between you and your doctor is mostly a load of fertilizer. The same can be said about “rationing.”

Anyone who bothers to think should know that medical care has been rationed for as long as money has been involved in the process. The most flagrant form of rationing is that which stems from our present health care non-system, that is, rationing based on ability to pay. And anyone who thinks that for-profit insurance companies don’t ration care must live on another planet. Guess what! They’re in business to make money! And they do it by rationing coverage. Regarding the gummint messing everything up, the facts are that the VA delivers high-quality care, and the overhead costs of the VA and Medicare systems are the lowest in the country. So spare me the baloney about how efficient private health care financing is by comparison.

Finally, I wonder how many of the reform naysayers who want everything to be privatized are holding true to their beliefs about government programs by refusing to accept Medicare or VA medical benefits; or how many of them would like to put their health care financing in the private hands of people like the recently newsworthy yahoos from Wall Street.



DENNIS WEIGAND is an Edmond resident.