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Viewpoint: The Irony of the Demand for Government-Run Health Care

Duling, Reginald MD

doi: 10.1097/01.EEM.0000502823.86703.fd

Dr. Dulingis an emergency physician in the Seattle area. He is the CEO of Eastside Emergency Physicians.



In our current state of discourse where every issue is highly politicized, an oft-repeated mantra is that “we'd all be better off if only we had government-run health care.” Make no mistake, private insurers pay a large portion of the bill, but the government does run health care. But look at what works and what doesn't in our current health care system, and the parts that might be classified as disasters can usually be traced to one source: the government.

The United States has a critical shortage of physicians. Who determines how many physicians are trained each year to provide supply to meet demand? The government. Specifically, there is a national shortage of primary care physicians. Why aren't there more primary care physicians? Because the government's payment system dissuades new physicians from going into primary care.

If you've wondered why your doctor now stares at the computer while you talk, creating a disconnect that harms the doctor-patient relationship and disenfranchises patients, thank the government. The thousands of mouse clicks doctors make every shift, the inordinate amount of time doctors spend on the computer, and the decrease in efficiency caused by electronic medical records are all courtesy of government mandates.

The government is now trying to reject the evils of the fee-for-service system, but it's the government's system, replete with ridiculous rules of reimbursement that have little to do with medicine, fairness, or common sense.

Most of us pay a pretty penny for an ED visit, and the government has made co-pays illegal for Medicaid patients, encouraging them to come to the emergency department for a pregnancy test rather than buying one in their local drug store. It also encourages them to bring their child to the ED so they can get a prescription for a bottle of Children's Tylenol rather than paying for it out of pocket.

The government has publicly blamed emergency physicians in my state of Washington for the abuse of emergency departments by Medicaid patients. The irony is that the federal government requires emergency departments to see everyone who comes to the ED, and the state government blames us for seeing them. Want more irony? Despite the state's “ER is for Emergencies” campaign, when the government wants something done that is clearly not an emergency, such as a routine physical on a child taken into state custody, where do they send these patients for nonemergent care? That's right: the emergency department.

Americans pay more for the same prescription drugs than any other country because the government has failed to control drug costs as most other countries have.

As all of us in emergency medicine know, the biggest problem facing most emergency departments is a lack of inpatient beds in hospitals. Who decides how many inpatient beds are available? In large part, the government does. Mental health capacity is even worse, with state and federal governments largely responsible for inpatient bed availability and funding, both of which are dangerously lacking.

The federal government enacted EMTALA legislation in 1986 that required emergency departments to screen and stabilize all patients regardless of their ability to pay. Since then, nearly a quarter of all emergency departments have closed while the number of ED visits has skyrocketed for 30 years, putting tremendous stress on emergency departments, hospitals, and providers. EMTALA requires emergency physicians to provide a staggering amount of uncompensated care, a policy that would not be tolerated were it thrust on any other profession.

The government establishes “quality measures” that far too often are not founded in evidence-based medicine and do not improve quality of care. The burden of regulatory compliance has suffocated the health care profession, encouraging consolidation and the movement of medical practices from being privately-owned to hospital-owned, resulting in decreased efficiency and competition and increased costs.

Prescription drug abuse has become the greatest public health threat in our country. Doctors are blamed for overprescribing powerful narcotic pain medications, but this is the direct result of government intervention in health care. The government determined that doctors were horrible at managing pain (to be fair, we were pretty bad at it), and required that pain be measured as a “vital sign” for every patient. The government also measures doctors and hospitals on how quickly patients get pain medication. The government equates patient satisfaction with quality, and intends to punish hospitals financially for low satisfaction scores, knowing that a patient unhappy about being denied pain medication will make patient satisfaction scores suffer. It should surprise no one that doctors responded to these pressures by prescribing more pain medications to be considered “good doctors” by government standards, undeniably contributing to the current epidemic.

The government has refused to pass meaningful tort reform to ensure that doctors who do the right thing yet end up with a bad outcome — something that happens in medicine and in life — aren't held legally and financially responsible.

Many doctors won't accept or treat Medicaid patients. Why? Because the government refuses to pay fair rates for their services, so those with a choice in the matter frequently opt out. Populations under the relatively complete care of the government, such as those in the VA and Medicaid systems, frequently receive substandard care.

All of these facts are contributing to a disturbingly high physician burnout rate, with more than half of U.S. doctors experiencing burnout during their careers.

By almost any public health measure, the United States lags far behind most of the civilized world, while paying far more for health care than any other country.

So the next time you hear someone say they wish we had government-run health care, please explain that we already have it and that the government has proven itself to be horrible at it.

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