National Health Insurance

Yesterday, I received in the mail yet another solicitation to join Physicians for a National Health Plan (PNHP). I used to belong, in the days when simple solutions seemd to me to be simply right. Since starting down the unconventional road of homeopathy, I have been more wary, and their applications have for the most part ended up in the recycle bin. But occasionally, I write them a letter, explaining my reservations about joining. In the letters, I express a number of worries that keep me from joining their well-subscribed to but as yet politically unsuccessful organization. First of all, PNHP never really says exactly what it is proposing. In its newsletter it posts massive volumes of clippings the editors have gleaned from newspapers and journals around the country, depicting the economic wastefulness of the current system. It then cites examples of systems, such as Canada's or other European nations', where their national health insurances have far less administrative costs. But PNHP never describes what kind of national health care system they endorse. These details are presumably too trivial to warrant our consideration.

Being against national health insurance simply means you are pro big-business, right? But what would a national system actually actually look like? Would it mean that only doctors and approved medical clinicians could do treatment? What about chiropracters, acupuncturists, osteopaths, or homeopaths? What would become of them? Would they be considered part of the waste too, since the evidence for their treatments is held in lower repute by mainstream medicine than that for more conventional treatments? Although trained as a psychiatrist, I have studied homeopathy in its application to primary care type problems for over 7 years, even though I have not done a family medicine residency. Would I be permitted to charge for my services? Or perhaps I would be banned from these practices altogether, relegated only to treating conditions that have been narrowly defined as "psychiatric."

In short, I worry about what would become of alternative medicine in general, and I also worry about what would become of my own practice. The PNHP literature does not address these issues, nor does it address the issue of how to handle the high costs of prescription drugs and medical devices, the high fees charged by physicians, particularly specialists, the low fees awarded to primary care physicians, the rising costs of treating self-induced medical problems (those based in behaviors or life-style choices), the effects of high malpractice insurance rates, and the impact of outlandish medical student debts on the practice of medicine. It does not address the issue that neither doctors nor patients have or wish to have any restrictions on the tests, procedures and treatments open to them, regardless of costs. Yet the costs are killing us.

National health care appears to be a Gordian knot kind of solution. It actually has a limited though valuable contribution to make, because waste does increase costs. but it can only be part of a broader solution. It addresses only one part of the problem, because national health insurance has no relationship to the underlying causes of our expanding health care system. The bureaucracy that adds costs to the system is not expanding, but costs are. And the reason is that doctors are prescribing more and more expensive tests, drugs, and other treatments, and patients are agreeing to more and more expensive drugs, tests and treatments. If we were to enact a national health insurance plan, we would soon find ourselves confronting these problems head on, and the system would be forced into rationing. And rationing might be done along any kind of guidelines, since PNHP and other advocates of national health insurance haven't evidently thought much about this. It might well be the death knell for many types of alternative medicine, including homeopathy. It might lead to a narrowing of all of our choices for health care. This would not necessarily be entirely a bad thing. But lets talk about what kinds of rationing we might favor, when we talk about national health insurance before it is enacted, not afterwards. Otherwise, we don't know what it is we are endorsing.