This business called medicine
Lisa Van Dusen
CMAJ 1997;157:1724-5
Lisa Van Dusen, a Canadian stand-up comic living in Chevy Chase, Md., is a former writer with Maclean's.
© 1997 Lisa Van Dusen
year ago I found myself sitting in my doctor's office in Ottawa, staring at the white rectangles on the wall where her degrees had once hung. Surrounded by boxes of files, I listened to her reasons for bailing out of Canada.
Given that I had left Ottawa for Washington, DC, 4 years earlier, I wasn't in much of a position to argue with her, although she wasn't heading south to be a stand-up comic as I had. (Not that she isn't funny. When I told her I wanted to go off the pill because I couldn't bring myself to stop smoking, she said: "If you'd rather smoke than #$%*, you've been #$%*ing the wrong people.")
As a very successful GP, she'd been approached by American headhunters for years. This time they had happened to catch her at a particularly low point in Mike Harris's relationship with Ontario's doctors, and she had taken the bait. She was headed for a salaried position in Mississippi. "Anyway," she smirked, "now that you've left town I'm just not as busy as I used to be."
It was a good line, but a bit out of date. Living in America is the quickest cure for hypochondria any physician could prescribe. Not only can you not afford to see a doctor more than once a year, but also some of the ones I have encountered have been walking arguments for psychic healing and reflexology. And make no mistake about it, health care in the US is not about health care. It's about money.
I recently decided to spend at least another year in DC, and have been shopping around for health insurance. When I first got caller ID on my phone it was to weed out the odd wacko I inspire in my line of work, but recently this feature has provided the added bonus of weeding out health insurance salesmen.
One of the first lessons a Canadian learns down here is that there's no such thing as a final offer, so I've been playing a little game of cat and mouse with the pitchmen in an attempt to bring my premiums down. So far it's been working, but if Joe Baum of Optimum Choice doesn't stop calling I'm going to have to pick up the phone and break up with him.
As a single mother with a 7-year-old daughter, the best offer I've had so far would set me back US$300 a month for managed care for both of us. That's for starters. Then there are the "copayments": $10 for annual checkups and up to $500 for inpatient hospitalization. I'm not saying it's extortion -- it's not as though they're saying that if you don't buy into their plan they'll come over and break your fingers. They're just saying that if you don't buy into their plan and you do break your fingers, they won't fix them.
There are other options. Throughout DC signs have sprung up that read: "Finally!! Group Health and Dental for the Self-Employed." The signs, complete with an 800 number, are nailed on DC's telephone poles alongside mugshots of lost poodles and born-to-be-wild tom cats. Suddenly, the option of heading north on Interstate 81 in the event of an emergency is looking more and more attractive. As long as my hands and feet are still attached, I can drive it in 9 hours. How much blood can you lose in 9 hours?
Having grown up in a country where health care's bottom line was the patient, it's strange to find myself living in a place where the bottom line is the bottom line. The preconceived notions Canadians have about doctors -- that they are deserving of respect and admiration -- go out the window down here because America doctors aren't in practice, they're in business.
When I meet a doctor in my neighbourhood I assume he's a plastic surgeon because Bethesda/Chevy Chase has the highest per capita number of plastic surgeons in the US. Downtown Bethesda also has more restaurants than downtown Denver, presumably so that after you've had your new breasts installed you'll have lots of places to show them off.
In October, a commission established by President Bill Clinton presented proposals for overhauling the American health care system. The Advisory Commission on Consumer Protection and Quality in the Health Care System suggested that health plans be banned from using "gag rules" that prohibit doctors from advising patients of all available treatment options. It failed to reach a consensus on such fractious issues as whether health plans should be allowed to exclude SICK PEOPLE; perhaps treating sick people wouldn't be a sound business decision.
Because the business of health care delivery is so lucrative, it has the same potential for graft and corruption as casino gambling and construction rackets. During a recent round table on health care broadcast on National Public Radio, a participant mentioned that a Senate committee investigating health insurance fraud had discovered that the Mafia is now in the managed care game in some eastern states. In other words, in some places they actually will come over and break your fingers if you don't buy into their plan.
When Clinton was first elected on a health care reform platform, he probably didn't realize what he was up against. The insurance companies here ran a counterattack that made the National Rifle Association look like Bambi with a little attitude. Their disinformation campaign about the Canadian health care system left Americans thinking that a universal system was some sort of socialist plot that would have them on waiting lists for appendectomies and perishing in emergency waiting rooms while welfare mothers got free collagen implants. It was a stunning leap of faith for Clinton to think that in a country with so many vested interests a good idea could sell itself.
Occasionally, minor reforms squeeze through Congress as political bargaining chips. One recent change was for a mandatory 48-hour postdelivery stay in hospital for new mothers. The insurance companies had been ruthlessly enforcing a 24-hour stay in a "here's your baby, there's the door, don't be a stranger" sort of way. A friend of mine who was in the final, yowling, human-cannonball/get-the-net stages of labour at 11:45 pm was quietly reminded by her obstetrician that if she could just hold off until midnight she'd get an extra day in the hospital.
Since the Clinton plan failed, health care reform as a public policy issue has been wiped from the political radar screen. Americans generally don't complain about this because they've never known another system and they tend to see Canadian-style medicare as government intrusion. They'd rather run the risk of getting a second mortgage on the farm for a heart transplant than have some bleeding-heart socialist commie in the Department of Health and Human Services tell them how to live their lives.
Nothing will change here because too many people are making too much money off the existing system. Down here there are doctors who bill whatever they want and a smelly subculture of medical malpractice lawyers who survive on fine print and nuisance suits. Meanwhile, I'll be forking over US$300 a month so I won't have a myocardial infarction every time my daughter climbs a tree. It's enough to make me nostalgic for barroom debates about Canada's constitutional amending formulas.
Recently, an ad for one of DC's larger HMOs started popping up on local buses. It has a photo of a smiling toddler looking down at a hand holding a stethoscope to his chest. The copy reads: "It's a diagnosis, not a business decision."
Don't believe it. In America, every diagnosis is a business decision.
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