Chinese puzzle

An important theme issue of JAMA this week, on the health of the nation. Alas, unlike NEJM, the continue to hide material of strong public interest behind the subscription wall. I condemn thee, I condemn thee, I condemn thee!

So, since you can't read any of it, you'll have to trust me to report accurately on what's in there. The problems with our health care system are complex and interrelated. Stuart Altman has compared it to a balloon -- if you squeeze it in one place, it expands in another. But I'm going to use the analogy of one of those 3-dimensional Chinese puzzles. It turns out that if you can find the one or two key pieces, you can take it apart easily.


Manya Newton and colleagues review literature about overcrowding in Emergency Departments and encounter some common assumptions that it is caused in substantial part by uninsured patients who use EDs inappropriately for routine care that ought to be provided in physician's offices. They find that in fact, uninsured patients aren't significantly more likely to visit EDs for non-urgent care than are insured people. Both uninsured and insured patients, however, do sometimes make visits for non-urgent care because they lack access to primary care services. Yes, insured people can get to see a doctor, but they might have to wait for weeks. Conditions that are defined as "non-urgent" in the sense that they can be treated in doctor's offices are nevertheless frequently much too urgent for a three week wait.

In fact, ED overcrowding is not caused by an increase in uninsured people showing up, it's caused by inadequate payment for emergency care leading to a shortage of services; inadequate numbers of hospital beds causing patients to back up in the ED; and inadequate supply of primary care, as noted above.

There is a severe and growing shortage of primary care physician services. It's difficult for insured people to find physicians who will take new patients; people who have physicians face long waits for appointments; primary care doctors don't have enough time to spend with the patients they do see; and they work long hours for lower pay than other specialists. I say "other" specialists because primary care is a specialty and ought to be thought of as such, not as somehow representing inferior or less advanced training and skill.

And by the way, we also face a severe and growing shortage of nurses, as documented by Buerhaus, Staiger and Auerbach in The Future of the Nursing Workforce in the United States: Data, Trends and Implications, reviewed in the same issue. The fact is we need to provide better pay, better working conditions, and more dignity and respect to both professions.

The two key puzzle pieces for fixing our collapsing health care system are:

1) Universal, comprehensive, single payer national health care,
2) Which increases the rewards for primary care physicians and skilled nursing professionals, and assures an adequate supply of well trained practitioners in both categories, so that we can take care of people properly.

Number 2 is an essential underpinning of the third piece, which is to allocate resources in a rational manner. I have discussed that before but I will have more to say about it shortly.

Meanwhile, there is no room for debate: Obama's proposal is at least a small step in the right direction, McCain's is a huge, radical step in exactly the wrong direction. Anybody who believes this is a matter on which reasonable people can disagree doesn't know Socialism from Rastafarianism.