Wednesday, September 1, 2010

Obama Transition Asks: What concerns you most about Health Care? (11.29.08)

[The Law of Karma.  A brief interlude.]

My main concern People falling through the cracks.  And how to address that under a Public Health umbrella.

We need not only universal health care - and in my view - a single payer system, but we need ways to track who needs what.  We need better Public Health.  In my view a Public Health System should literally do a census of the country.  I know that sounds impossible.  But I'm envisioning making use of the already existing ground-network the Obama campaign used to such efficiency.  If the neighborhood networks (in battleground states) were replicated all over the country, and volunteers (I'm sure Obama could raise an army of them with one appeal to the nation) fanned out across the land, armed with a public health questionnaire, to locate the elderly, the disabled, the frail, people with chronic illnesses or newly diagnosed, etc - as well as people facing unemployment and losing their homes and other financial difficulties - ok, I know this sounds pie in the sky - but we need an accurate accounting of where we are as a nation in terms of our health and the people affected by current social upheavals (which affect their health!).  Only then, once we're got a data base of who needs what, could Public Health decide how to allocate both professional resources (whether for prevention or ongoing assistance) and the implementation of a volunteer cadre to assist the elderly, the disabled, etc.

I'm a psychologist.  A therapist.  And I'm also in the middle of the muddle that is our health "system" but which too often is not "care."  I'm in a position to see how so many things interact and can affect one's health and one's mental health.  I know that simply a bunch of changes in one year, whether positive or negative, can lead to physical or mental difficulties.  I know that too many people fall through the cracks, due to ignorance or pride, or a feeling that no one cares or no one is there to listen or assist.  We've had this national fantasy that everyone is self-sufficient.  People feel guilty in this country for simply being in need.  We guard and protect people's self-sufficiency, but we don't have a social mechanism to protect them when they're really in need and don't know where or who to turn to.

Insurance is out to make a profit.  We know this.  Managed care is driving providers nuts - on purpose.  We know this.  Treatment decisions are too often taken out of the hands of professionals and given to people who make a profit from denying care or from putting obstacles into the way of receiving care.  People who are ill, particularly people who are mentally ill or cognitively unable to process all the information or access the sources of help (even if they existed!) shouldn't be saddled with trying to decide which insurance plan or drug plan (Medicare Part D is perfect example of this nonsense!) to use and whether to change it every year.  And they can't be saddled with having to navigate insurances and everything else all by themselves.  It's really a totally unfair system, right now.  Rigged against providers, against patients, against a system of care which could so easily be set up in a non-profit way.  Why do we need so much duplication of possible agencies, insurances, paper-pushers and overseers, etc - when all of that only makes it harder for those who are most in need of the services - by facing them with too many choices and hurdles?

Those who've controlled the fragmented pieces of this health care dysfunction (we call a "system") have made the case that "choice" is what every American wants.  As if my husband, newly diagnosed with cancer, is going to do a survey of all possible providers to see and find out their backgrounds and their preferred methods and so on.  Nope!  Maybe if you're Senator Kennedy, you have people to do that for you.  But most of us don't.  (We access the already existing little part of the system we're plugged into - that is nearby - and take it all on faith!)

Choice should involve primarily picking a primary care physician, who is hooked up with a medical center you trust.  That physician should be surrounded by nurse practitioners and physician's assistants (and ideally psychologists, like me, to do a consultation if the medical person thinks it's advisable to have someone talk to them at greater length - or even on a regular basis).  Doctors should be paid for their time, not the service they provide.  And medical education should be financially assisted by the government, so that no one has to go into a high-paid specialty to pay off loans.  (which has led to too many specialists - in cities - and too few generalists anywhere)  We need more primary care people.  We need them to spend time with the patient.  We need them to be able to follow that patient over years, not changing doctors and patients all the time, due to insurance changes... which seem deliberately engineered to interrupt care and thus make greater profits for their share-holders.

So I picture a primary care setting where patients really can truly find a heath care hub.  Where doctors are not spending time arguing with insurances or trying to find out which medication might be on that insurance companies "list" of meds they actually pay for.  And so forth.  Where the doctor's office (or hospital) does not require personnel to list more and more procedures and so on... so as to find ways, from their end, to game a system rigged against them.  (We have armies of insurance people reading charts to try and deny care along with armies of people assisting the medical system reading the same charts to find every jot and tittle to claim for payment!)  Yes, I picture a system where, instead of assuming self-sufficiency on the part of every patient,  we make sure that care for the frail, the elderly, the new mother, the handicapped, the chronically ill is followed up by Public Health workers (or volunteers), making sure no one drops the ball and no one falls through the cracks.  Continuity.  Treating each one with dignity. 

I'm sorry.  Health care should be like the public school system.  A right for each person.  A duty exercised by society.  Ok, if people prefer a "private" alternative, that's their choice.  But it should not be the norm.  We don't seek choice for our electricity.  It's there all the time.  Whether we need it right now or not.  Just plug things in when they're needed.

We know from research that many stressors, family conflict, workplace disruptions, financial hardships etc, contribute to mental health problems and physical health problems.  We know that not having paid vacations and paid sick days are a recipe for getting physical and mental problems.  So much of this is all interconnected!  Helping people handle stress or change (through access to mental health) prevents overuse of medical care.   (Contrarily, a plethora of choices and insurance hurdles adds to stress of any illnes and thus to the potential for further setbacks in the healing process.)

So I'd like to see Public Health as a kind of overarching umbrella, making sure people don't fall through the cracks.  Making sure that as seamless as possible a health care system is put in place.  Making sure that Public Health nurses, for example, visit the frail and elderly on a regular basis or call them in for evals - just to check on them.  Making sure that young mothers receive extra assistance or information or whatever, so they can adequately handle new responsibilities.  Call it pie in the sky - but it can be done - and far easier than raising an army! 

Right now there are so many ways that our current system leaves people floundering.  Confused.  Disregarded.  Overburdened.

This can't go on.  I myself have nearly stopped practicing psychotherapy due to utter frustration with the way insurances have made it difficult to treat and bill and so on.  There's no safety net any longer for therapists.  It's as if we're left to try and deal with suicidal people on our own.   Denied enough visits.  Denied payment.  Denied hospitalization as a way to protect people in a crisis - except for a day or two - if we're lucky.  It's insane!  I would gladly sign on - for free - to assist in setting up or monitoring a system that prevented people from falling through the cracks.  I'd gladly work - for free - to monitor ethics and so on.  I'm very concerned about our nation.  I'm concerned about those among us who are the "least" and the most "vulnerable" and unable to fend well for themselves.  This is breaking my heart here.  I'm seeing it with my elderly parents - still at home - wanting their independence - but no longer able to really notice and think through what they might need - and honestly, at a certain point in life, the elderly are often best served by dedicated strangers than by family members (where there's no baggage on both sides that gets in the way).

So I come back to Public Health.  Everything should come under that, I think.  Enfold the NIH.   Enfold the Military health care system.  Enfold the VA.  Enfold Medicare.  Enfold Medicaid.  Enfold private hospitals.  Ok, enfold me too!  Enfold it all under Public Health.  I suspect that by integrating already existing parallel systems into one whole integrated system, we'd be better off.

Consider this.  If a person goes crazy, why should we worry if it's a Vet with PTSD, to send them to a VA (hours away?) Or if the person is homeless or has insurance or not.  Or if they're "free" to just be homeless and crazy (because you're giving them a choice!).  No, if someone needs care, whether it's due to a broken leg or mental illness, that care should simply be provided.  At a place nearby.  No soldier should have to prove their difficulties are due to war - in order to get care or benefits they need.  And neither should anyone else.  If they've been a victim of incest in childhood, that should be as important to our society as if they've gone to war and been driven nuts that way!

Too many people are falling through the cracks
.  Now is the time to get this right.  Can't we do that?  Can't we access the professional skills and experience of people like me in setting this up?  I am sure I am not the only person willing to volunteer time and energy to make sure we do better as a society.  I've been blogging like crazy during the election.  Now I'm blogging here this morning. Yes, Karma sent me:  I'll admit that with a husband facing cancer treatment - who's 69 - and my elderly parents, clinging to their independence but really needing way more social assistance - at 86 and 91, I'd be thrilled if the public health census person showed up at my door and asked me if there was any way I or a family member might have medical problems and the consequences of aging or ill health.  I too need help - right now!  Yes, I'll cope.  I'm well at the moment.  But suppose I get sick too.  Then what?  Nobody but me to fight the system with my catastrophic coverage only!

Public Health:  The right to live with dignity.



We've had this national fantasy that everyone is self-sufficient. People feel guilty in this country for simply being in need. We to guard and protect people's self-sufficiency, but we don't have a social mechanism to protect them when they're really in need and don't know where or who to turn to.
Exactly. Hardly the only myth, another is that we get the best medical care in the world here. A quick look at infant mortality rates is an easy indicator to see it just ain't so.
Some things should not be an opportunity to generate profits for the few at the expense of the many. Water distribution is one, Heating, another. Essential Services. Healthcare falls under that category by definition.
Nice to see you. You've been widely missed.

Thanks for your kind words. I'm still trying to take a break, but duty called.
(you accidentally flagged a typo for me - I'll fix it)
As always, TheraP, you're right on the money. I wonder sometimes if I would have sought help when it could have done some good 40 years ago if it would have been available without cost or the "shame" which society unfairly places on those who suffer from PTSD. Probably not....
Anyway, thanks again for your support and kindness over the years. You're the kind of person "We" need. There aren't enough of you.
You flag a whole other issue. Shame. The blaming of people who are suffering, the stigma attached to having emotional problems. The idea that "men" are brave and strong. That being vulnerable or in need is a personal failing. Yes, we are all in need. If we start from that basic fact, our basic humanity, then we can get change - without shame: Yes. We. Can.
Good to see you, Chuck!
Great post TheraP. I helped a homeless man I met get treatment for some physical problems he had about two years ago. As you said these people in particular are poorly equipped to navigate the healthcare that may be available to them. He was a veteran, which opened up some avenues to him that weren't available to others. He still needed me to transport him about 55 miles each way to the VA.
The costs of supporting the profits built into the current Insured-provider-insurer system are costing this country a significant portion of our GDP. It's time to get real and cut out these extraordinary profits, (there's no reason an MRI should cost 10 times more in the US than Japan), and streamline the process of getting treatment. It's time we as a nation realize that providing timely and adequate treatment will result in net savings through prevention/wellness as well as just being the right thing to do.
Bless you for your kindness. And thanks for sharing that touching personal experience. For some reason it reminded me of a young lady with a toddler, hitchhiking by the side of the road on a rainy afternoon (more than 35 years ago). Her boyfriend had hung himself that morning. And we were on our way to a small gathering of caring people, once we dropped her off at her parents'. The whole little group was so moved by this story that we all ended up going to the pauper's funeral of that young man, who had preferred to die by his own hand, rather than face a parole violation hearing and the potential of going back to jail. Just another example of someone who must have fallen between the cracks.
There are so many stories.
As usually happens when reading your posts, I get to thinking about only one thing because my mind is relatively tiny.
When talking about the problems with providing "mental health" to the nation, the issue that towers above insurance policies is the fact that the infrastructure of hospitals and other state sponsored institutions were wiped out a couple of decades ago.
Your point about being able to create a database that would stand above the squabbles over who pays for what mirrors a more fundamental call for change.
The present set up limits liability through controlling how a problem is reported.
Brilliant insight, moat! Maybe you could enlarge on that a bit - here or elsewhere.
I had an occasion to hear a man recently who had analyzed the rise and fall of a small community mental health center. And one wonderful aspect of their now defunct program, which was hugely successful, in assisting people who had been discharged from a mental health inpatient program, involved training volunteers to be therapy visitors, for wont of a better word. These people went out to visit the discharged patients and followed them, sometimes for years in a kind of informal way but also connected with the mental health center in terms of receiving supervision and consultation as a kind of ongoing assistance in their volunteer capacity.
Sadly, this "experiment" with the volunteers, which was so successful, had to be discontinued for liability reasons.
We need better Good Samaritan Laws, isn't that sad?
Your request is a fair call to duty. I will try to deliver after assembling various parts. So it will probably be in another place.
Your story about good work being stopped by liability concerns hits the mark. What I am mulling over is how the power of "diagnosis" plays a part in the dysfunction.
I look forward to your thoughts.
Amen, Thera.
Just, amen.
In Paul Krugman's book CONSCIENCE OF A LIBERAL he uses the phrase "Medicare for all". Ideally, that's what I'd like to see.
What concerns me is the cost, I wonder how a nation of educated hypochondriacs will respond to unlimited universal health care or any lack in either its unlimitedness or universality.
See any other first world industrialized nation.
Geez, hyperbole much?
You have managed to put into words what many in the medical world feel. I work in the Workers' Comp industry in California and would be more than willing to donate my time to any effort to fully revamp our medical system. Thank you for your post.
Thank you for the validation and encouragement!
worker's comp - excellent piece to the rest of it!
TheraP --
So good to see you -- you are missed; there's a hollow wind tunnel sound where your music-to-our-ears was for so long.
I second the idea of your national health census. There are so many people who simply can't cope by themselves with the maddening bureaucracy of the health industry -- not only the frail, the elderly or the befuddled, but anyone with a limited tolerance for either arrogance or ignorance.
My parents both died relatively quickly when they were relatively young. But I have helped my cousin find options for coping with the various stages of assistance her mother has needed, and continues to need, now that she is 95.
If I can be of any help to you vis a vis options for your parents, while you are supporting your husband through whatever treatment is required, please say and I will create a new email account so that I can post its address here for your use.
In the meantime, thank you for your encompassing concern for all those in need. Surely that care will not only help others, but come back to you as a karmic blessing.
Thank you from the bottom of my heart. For this and your comment on the blog from Tues. I actually had not read any of those comments till yesterday... and I'm deeply touched - beyond words.
With regard to the parents, options for coping abound. The biggest obstacle is the "dad" - who is used to being "in charge" - and has been presented with literature (which he left behind Tues afternoon in the ER... believing he could get info, should he need it, "at the Hospice" - ummm, no.) But I'm going to do an end run - and have already left a message for his pastor, whom he reveres. And I'm hoping the parish nurse (if they have one) can be of assistance and that the pastor can make up something about the confirmation class doing "service" as part of their class (why not?). I've decided a frontal "assault" here is pointless. If The DAD comes to believe he is "helping" young people to be better Christians... so much the better!
If I need further assistance, I'll let you know. Actually, I already have a couple of email accounts that could be used if we needed them. They got set up much earlier related to either problems or fun at the Cafe. Or, another possibility would be to make use of someone's website with private messaging. If we should need that down the road.
Karmic blessings abound. Many events this week have come to me like a "hug from the universe." Sometimes, it takes suffering to bring you to a place from which something can blossom. I think I've stumbled onto a garden - and will do my best to tend it and enlist all of us who want to do so to plant seeds and water them and so on.
This post is just a part of something larger. An email friend just called it: The Web of Life.
I don't know of a first world industrialized nation where people seeking universalized free access health care find it completely adequate and satisfactory. What do the French or Germans say about their medical services, how about Britain? I suppose if you compare health care in different developed economies some have better systems and apparently the US doesn't provide as much as some other places, but I haven't heard all this praise for the EU's medical services. In Spain they've got a fairly good health care system with the latest technology and plenty of doctors, but workers find a third of their salaries deducted in taxes. Would this be the prescription for the US?
Thank-you for the extensive and interesting post. As a resident of one of those countries blessed with nationalized healthcare, I can vouch that there are still many problems -- even major ones. We see the same, of course, with our own education system, to which you compare healthcare in terms of a right. But at the end of the day I'd still rather be working out the problems faced by a system that starts from the premise that healthcare is a universal right -- rather than trying to patch together solutions for the many gaping holes in a system that starts from the premise that health is a privilege.
I've experienced the Canadian system first hand years ago - my son was born there. My husband was a welfare worker there at the time. We've camped all over Canada. And I've seen the signs for clinics in the most outlying, far to reach places. I got compassionate care at a tiny ER west of the Canadian rockies when I twisted an ankle (in a car wash, of all places!). We've been as far as Labrador and New Foundland etc.
I've also seen second hand the system in Spain and we have 3 nieces and nephews current training in Medicine there.
I'm not looking for perfection. If anyone is... well, you need help! But we need to aim as high as we can.
Thanks for your response here. And congrats on delurking! I can see you've posted many things already. And I look forward to more.
Well said TheraP. I, also, am a therapist and am stressed out and many times ready to quit. Not having anything to do with my clients, but yes our health care system, the insurance companies the mighty gatekeepers are the ones that keep me up at night.
Wonderful post
Yes, I agree. It's not our patients. It's the system we and they are trapped in. Many times I have seen people for free because it's easier than the alternative.
Glad to know your background, Ava. Peace. Solidarity. And Sanity!

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