Nobody’s Right If Everybody’s Wrong

A renowned family physician explains what the rural outcomes of proposed health care reforms are likely to be. Take a deep breath.

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We used to have a saying when I practiced medicine in rural Tennessee, twenty-five years ago: ‘Nobody with congestive heart failure lives in Hancock County.’

I was then a National Health Service Corps physician, serving in the Hancock County Health Department for three years — payback for getting my medical education for free from your friendly Federal government.  This big government program was designed to help rural (and urban) places make sure there were enough doctors, because doctors tend to like to live in suburbs and see people with money, a proclivity that steers doctors away from the urban and rural poor. 

By ‘nobody with congestive heart failure lives in Hancock County,’ we meant ‘lives’ in both senses of the word.  We meant that no one with congestive heart failure survives in Hancock County, because when people with congestive heart failure got into trouble, in those days, they needed a hospital, a cardiologist, and an ICU to keep them alive; Hancock County didn’t have two of those things.  We also meant that no one with congestive heart failure resides in Hancock County.  In those days, if you had bad congestive heart failure, either you moved to Knoxville or you died, plain and simple.  (The truth was that even if you moved to Knoxville, you didn’t live that long anyway.  In the 1980s, the life expectancy of people with bad congestive heart failure was just a year or two.)

Health care and health care reform in rural America is filled with that kind of irony.

On the one hand, people in rural America don’t have enough access to health insurance, high-tech hospitals, specialists, primary care doctors, emergency rooms, dentists, drug stores and other health services.  On the other hand, access to health insurance, hospitals, and so forth aren’t what make people healthy.

A rich community life, which is more likely to exist in rural than in urban areas, is probably the most important factor in keeping Americans well. Yet we’re spending trillions of dollars on unnecessary health services, so expensive that we don’t have enough money left over to pay for what actually matters – the time to be together and learn from one another, money to keep the streets safe and an environment vibrant.

The health care reform that’s being proposed for the U.S. and its likely impact on rural America are turning into a bad joke: there is a huge contradiction between what we are considering, what we are likely to achieve, and what our legislation is actually likely to do.

What we are considering is mostly health insurance reform.  That is, we are trying to change the rules about health insurance so that we get more people insured (using an insurance mandate, which means you have to buy insurance or pay a financial penalty to the government), so that insurance companies can’t refuse to insure people who might actually or do get sick, and so that insurance will cost less and people can actually afford it.

Some people want us to use what’s called a Public Plan, essentially a government insurance company that would work like Medicare and could compete with private insurance companies, the idea being that competition would keep costs down.  Other people want to use insurance purchasing exchanges or coops, which would provide a bunch of different insurance plans together and make them offer the same benefits. This approach, too, by offering people more choice of insurance plans, is designed to create competition and keep costs down.

Neither a public plan nor insurance purchasing cooperatives have ever been tried in this country, and there are lots of people who think neither one will be effective in controlling health care costs.

Health Resources and Services Administration, Bureau of Health Professions, July 2009, via RAC Online
The National Health Service Corps determines priorities for assignment of clinicians. Scores range from 1 to 25, with higher scores (in darker red) having greater need for primary care physicians.

There’s also lots of language in the six or so health care reform bills floating around Congress about improving primary care and prevention.  Most people think we’ll give more money to the National Health Service Corps, which is what put me through medical school and sent me to Hancock County.  And there is even more money directed at Community Health Centers, the places that actually provide health care for lots of people in rural America and serve as the model for what a health care system in the U.S. would look like, if we ever got around to thinking about building such a system after all.

What do all these proposed changes mean for rural America?

First, the bad news: Health insurance reform is going to make health insurance more expensive, and that expense is going to be hard to bear.  When you include more people, it costs more money.  On the up side, including more people should mean greater fairness and stability, and perhaps somewhat better population health. But most of the short term benefits will flow to insurers, who’ll get 50 million new customers, and, perhaps, to some mostly-urban hospitals, which won’t have so many uninsured people undermining the profitability of their expensive services.  There are going to be subsidies for lower income people, which will reduce the pain somewhat, but, as of this writing, the subsides are in the form of tax credits, meaning you lay out money all year long and get it back at tax time, a schedule that’s tough if, like most of us, you are on a tight budget as it is.

Associated Press, via Wall St. Journal
At Camillus Health Concern in Miami, a federally funded health care center that treats low-income and homeless patients, Dr. Ross Collazo talks with Rafael Cabrera. Most of the proposed health care reforms under consideration would increase funding for such community health centers, urban and rural.

Now the good news for rural America.  There’s lots more money for Community Health Centers.  Assuming that money stays on the table (always a big if, in Washington, where big insurers, big pharma and big medicine are banging at the refrigerator, each demanding their share of the pie), there is a chance people in rural America will get more of what they need, which is not more insurance, but more doctors, more dentists, and more of the health care that matters.

So health care reform will cost way too much, get lots of people access to care they don’t need, but probably will bring more services to rural areas that do need them.

Could we just skip the insurance step and build Community Health Centers for all Americans?  Of course we could, but like the person with congestive heart failure who couldn’t live in Hancock County, people who think about what we actually need don’t seem to live in Washington D.C.

Michael Fine, M.D., the top ranked family physician in Rhode Island (ten years running, in Rhode Island Monthly’s Best Doctors in RI), is an author, community organizer and health policy expert. Dr. Fine is also the managing director of Health Access Rhode Island, a network of family practices that provides affordable primary care to people without insurance.

 

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