Last week I took a trip back to my home State. I helped teach a group of military surgeons from all over the world at the National Center for Medical Readiness at Wright Patterson Air Force Base in Dayton Ohio. We had several hours at the end of the course to talk about the State of Medicine and Public Health—different issues that are often times confused. Most of the students were American military physicians, but we had students from Australia, S. Korea, Japan, New Zealand, The Netherlands, Egypt, Canada, and The Philippines.
Interestingly very few of those countries have organized trauma systems that incorporate civilian institutions into their Emergency Disaster systems and only one country, Canada, have organized civilian trauma systems and these are not organized across the Provinces but are local pockets in mostly urban areas.
New Zealand, for example, has no trauma system and Australia has very limited public support for such costly trauma system development. In formal discussions and informal surveys all the students would prefer having a complex medical problem taken care of in our country instead of their own. The one exception was Germany on this count. Complex problems included complicated neonatal care, cancer care, heart disease, and trauma. This did not surprise me.
What did surprise me was their ambivalence about the State of primary care in their countries. Many reported rationing of resources in the form of prolonged waiting periods for evaluation of everyday situations. Diabetes, prostate and GI cancer surveillance and follow-up for heart disease. This was surprising to me in light of what we have been told recently in our country about the efficacy of preventive medicine. One American Physician who had gone to Medical School on a Public Health Services Scholarship and recently finished her 5-year obligation to the Indian Health Services was very negative about the quality of care available to Native Americans utilizing those facilities. The allocation of scarce human and physical resources was “uniformly disproportionate” resulting in routine delay in diagnoses and delay in treatment.
Her comment could have been made by any number of physicians who have served in our military, VA, or Indian Health Services. Her experience and others are anecdotal, but they all recommend controlled morbidity and mortality studies of these government agencies and believe that such studies would shed light on the quality of care available via single payer systems. The ongoing Oregon Medicaid study showing no impact on morbidity and mortality of patients on Medicaid or other indigent populations except in the areas of mental health and drug rehab was sited.
These were all interesting insights to me because my experience with younger physicians most of whom have been trained in large urban-centered publically supported Medical Schools is that government-run Medicine is not such a bad idea. What is the difference between these two groups of young physicians? Those currently serving in the military or public health services have experienced the limitations and frustrations of working in a command and control top down economic system. They, in fact, point out that they are working for the government and not for their patients. On the other hand, those younger physicians many of whom are residents and interns have no real experience with working in those environments.
It is not my purpose in this discussion to talk about the economic implications of socialized medicine—that will be addressed in another article. What is pertinent to this discussion is the folly of unintended consequences. An ER doctor and Professor of ER Medicine at Wright State University told me that one in five ER presentations in Ohio are for drug and alcohol-related problems. Anyone who has read “Hillbilly Elegy” by J. D. Vance knows the story of the drug problem in Southeastern Ohio. My colleague pointed out that things became worse in Ohio with Medicaid Expansion. It is estimated that over half the cases of drug-related ER admissions in Ohio are from the Medicaid population and this is up from 25% prior to expansion—The Medicaid population in Ohio is only 8% of the population. Since expansion, there are twice as many people on Medicaid as there were 7 years ago and the cost of coverage of this population has more than doubled with increasing premium costs not only for the Medicaid program but for everyone across the board.
Milton Freidman famously stated “that the road to hell is paved with good intentions” So in Ohio it has been decided that the access to the opioid antagonist Narcan should be universal and would not require a prescription from a health care provider. Those supporting that legislation believed that they were being compassionate and caring but the proof is really in the pudding.
The result was not anticipated. Sales of Narcan at cost to many pharmacies, have almost tripled. But when addicts had access to Narcan they have been given a sense of false security and have been increasing the amount of opioid—synthetic or otherwise, they are taking resulting in a higher rate of opioid overdose admissions to ERs and opioid-related deaths.
This same physician related to me that he had been all in for John Kasich “governmentalist” Medicaid Expansion, but over the last year, he has come to the conclusion that Medicaid has made the drug problem in Ohio worse and not better and at great cost to the citizens of Ohio.
This same Professor of Medicine runs a drug rehab center in Dayton. As expected admissions to drug rehabs have increased significantly since Medicaid expansion. On the surface, this should be good and anticipated—increased access. But not reported on is the recidivism rate of the Medicaid population is significantly greater than those paying for their own care or who may have these services covered by commercial insurance. He noted the recidivism is much improved if families or employers pay for the services, instead of having the government subsidize those services.
So I am reminded of a comment I overheard after my team was beaten in the Ohio State Football Championship in 1966. The coach that beat us shook the hand of our coach and said “we look forward to beating you next year” Our coach replied—”We’ll see”
So to those who helped pass the Medicaid Expansion Bill congratulations. You ran a great campaign. Your win proved decisive. To your promise of improving health care to the people of Idaho and improving access and cost and clinical outcomes, I have only one comment.
“We’ll see” Be aware of unintended consequences.
Finally, I want to incorporate a new name into our discussions about government health care. The adjective my friend used describing John Kasich seems appropriate—”Governmentalist”.
In my dictionary, “governmentalist” and “compassionate conservative” means the same thing. In economics, the dilemma of the public good and the motives of individuals and families acting in their own unselfish interests is theoretically addressed by economic externalities. These do not take the form of increased taxes or regulations, but by the application of incentives that facilitate transactions that all parties have a vested interest in.
In our State what surprised me most was that our Governor who by his example during his 40 years of public service taught me several of the lessons I alluded to above came out in favor of Medicaid Expansion. Maybe I was naïve or just unfamiliar with the political quid pro quo and the influence of money on the political process—but boy was I surprised! He says he is compassionate, but maybe after having served so long in government, he sees himself as an agent of government and not of the people.
Agency and asymmetry. Who do I work for and how much support to factions should I give? If the IHA/ IMA/ IACI and other large industry special interests are disproportionately represented—who represents the people?
Agency and asymmetry. Conservative or governmentalist? Maybe people like John Kasich should form a new party—The Governmentalist Party. Hopefully, nobody from Idaho would join. Hopefully, we will not be for sale to the special interests—ever again.
Cost before coverage
Coverage does not equal access
Access is not Quality