Tuesday, September 15, 2009

Health reform letter to the editor

I wrote a letter to the editor of a Baltimore Jewish publication. It sounds like they will not publish it, so here it is:

Dear Editor,

As a graduate of both Shaarei Tzedek Medical Center's Schlesinger Institute Medical Ethics program in Jerusalem and Harvard's Ph.D. program in Health Policy, I was excited to see an article on the health care reform debate in this month's WWW because there are certainly Jewish perspectives on the issue. I read it through eagerly but was disappointed that the piece turned out to be boiler-plate rhetoric with a tenuous connection to facts.

For instance, the author says "there is no one in the country who is really uninsured" because everyone can just go to the emergency room and hospitals get reimbursed for that care. This system actually jeopardizes the health of both uninsured patients and hospitals: patients delay seeking care until an emergency, and hospitals go out of business because reimbursement does not directly cover uncompensated care but rather comes indirectly. For instance, a hospital which gives more care to uninsured might make 5% more on hernia operations; unsurprisingly, books do not always balance.

Other claims were irrelevant distractions, such as about end of life care. Government programs already cover the most vulnerable patients such as the elderly, certain terminally ill patients, wounded military members, and veterans through the government insurance program Medicare and government health care provided at Veteran's Affairs (VA) and military hospitals. End of life care is clearly not an issue with these current programs.

Far from ending life, government-provided health care at VA and military hospitals has saved lives in this war that would have been lost in the nation's 9 previous wars. These lives were saved due to comparative effectiveness research, the field funded in the stimulus package for $1 billion that was unfairly maligned by conservative commentators as leading to "death panels." In the 1990-91 Persian Gulf War, 24% of injured soldiers died from their wounds --- the same proportion as in Vietnam and a bit higher than the 19% in the 1898 Spanish-American War and 21% in World War I --- so technology does not seem to be the key factor in reducing wound fatality. In the current wars in Iraq and Afghanistan, only 10% of injured soldiers died from their wounds, largely because of improvements in care delivery (Gawande NEJM 2004). Health services researchers discovered that battlefield stabilization of injured soldiers and rapid movement to US military hospitals reduced wound lethality. The resulting "government interference in the doctor-patient relationship" literally saved twice as many lives as would have been saved by the old system in which battlefield surgeons held onto patients as long as possible rather than moving them through the system.

The Rabbis of the Talmud teach us not to be like the men of Sodom who would say "What is mine is mine and what is yours is yours." Many of us are lucky enough to have secure jobs with stable health insurance, but even giving tzedakah [charity] to pay for the health care of the uninsured is not enough to help the uninsured. Hospitals charge much higher prices to uninsured individuals, while insurance companies have leverage to insist on lower fees. If Sodom had a modern health care system, they could model it on this situation: discounted prices to the rich (health insurance companies) and inflated prices to the poor. Any solution that perpetuates this inequality in pricing between privileged and poor perpetuates the health care system of Sodom.

Prevention is the best medicine, of course. May we all have a new year of health so that we do not personally need the health care system.

Janet Rosenbaum, PhD

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