June 19, 2009
President Barack Obama
1600 Pennsylvania Avenue NW
Washington, DC 20500
Dear Mr. President,
I am writing today about universal healthcare. I disapprove of your endeavor to provide healthcare as an entitlement to Americans. I have no illusions about my ability to change your mind, but I do enjoy sending you an email now and again to remind you that Americans didnt actually vote overwhelmingly for change, as you enjoy saying. Americans only voted slightly in favor of change as your election victory last November was by just a few percent, which is nearer to President Bushs election victory in 2004. But yours was against McCain! He cant even emailhe cant even put on his own jacket!
So from the other half of America, from the half that you like to pretend doesnt exist, heres a new way to consider your healthcare plans. I wont analyze specifics. Everyone is already doing that. Fox News will hammer you from the dissenting side, while ABC airs their thinly-veiled universal healthcare infomercial from the Whitehouse. I, however, want to look at the issue at its most-elemental level. I think that with respect to healthcare, the government has a conflict of interest. I will elaborate on why.
Lets examine good healthcare. What makes good healthcare good? What sets it apart? One could assert that a good doctor is key, or a good pharmacist, hospital, dentist, nurse or therapist. One could substitute in any clinician type, facility, or combination of these after the word good to correctly answer the question, but this isnt enough. If we stop there, we havent gained real insight. To effectively answer the good-healthcare question, we must look deeper. What is excellence in a doctor or hospital? How about a pharmacist or nurse? I expect that you are more accustomed to considering what makes a good healthcare plan; however, we must not let ourselves become fixated on just health plans if, consequentially, we forget what remains central to quality healthcare.
To get to the answer, lets begin with a more specific question: what makes a good clinician? Clinicians enter their respective healthcare schools with different ambitions and motives, but once at these institutions, they all more or less have equal access to the same information; after graduation, they are all held to the same standard in the examination process. Clearly, we cant declare clinicians to be good or bad based on their exam scores. The exams are pass/fail. If a clinician passed, the consumer can be reasonably assured that they are knowledgeably competent to practice medicine. However, almost any consumer will contend that there are indeed good and poor clinicians, even though we are assured (and rightly) that all licensed clinicians know their stuff. If knowledge is not the pivotal issue, what else is there?
Many patients would like to choose their own doctors based on perceived experience. Some patients are adamant that they dont want some kid fresh out of school to be their doctor. Are consumers well served by applying the experienced-is-better rationale to choosing a clinician? Certainly surgeons and other specialists benefit from specific repeated experience, but when considering primary care doctors or one of the many varieties of non-M.D. clinicians, Im not convinced that the new clinician fresh from school is any less desirable than the old hand whos seen it all. Consider information, as it relates to medicine. Have you ever held a PDR? It is not possible for a clinician, regardless of their experience, to know everything in that reference. Nor is it necessary. Clinicians arent working on a desert island, and with the right computer skills, the entire worlds knowledge can be tapped from any computeralthough accessing it efficiently is practically an art. Furthermore, its the art of the younger generation.
I postulate that young clinicians can find the information they need faster and more efficiently than old clinicians. Im not a doctor, but I regularly use my Blackberry to find very precise information about anything in the world, at any time, from anywhere. My senior acquaintances are flabbergasted (and sometimes frustrated) that I can end a dinner-table debate by researching the correct answer to a question about some obscure/disputed factwithout even leaving my chair. Internet research and computer data sorting is an acquired skill that almost all young people possess. And I want for my doctor to be better at it than me.
If you accept the above two premises, we can generalize that good doctors arent distinguished by superior knowledge or even experience. There must be something else. Perhaps it is more motivational than practical.
Lets look specifically at doctors and their motivation. We all understand that there are people who decide to be doctors because they want to make money, while others earn an M.D. because they feel somehow called to help others. There are indeed exceptions, other motives, and infinite shades of grey. It doesnt have to be one or the other. I do however insist that at least some doctors fit well at one far end of this spectrum. I am acquainted with doctors from each motivational background. I feel comfortable generalizing that we would all rather visit the latter. I firmly believe that, more than knowledge or experience, this motivational foundation plants the seed for excellence in a doctor.
Since I have referenced motivation present before medical school or perhaps much earlier, the question remains: how do compassionately motivated clinicians distinguish themselves after medical school? Hold that thought.
Mr. President, I recall that you regularly praised your own federal healthcare system during your campaign. You repeatedly stated that your plan for nationalized healthcare was motivated by your desire for all Americans to share the high-quality healthcare system that you and John McCain have enjoyed as senators.
Mr. President, I believe that you have received excellent healthcare as a senator, and I believe that you are genuine when you state that you desire for all Americans to have access to this same healthcare. However, your statement betrays a fundamental lack of understanding about how healthcare works. I am familiar with your background, and I dont fault you for lacking healthcare experience, but please listen to people who are pros in the industry: your health plan had absolutely nothing to do with the superb quality of healthcare you received as a senator.
I am familiar with your doctor in Chicago. I know he is a reputable man who is part of a practice which has treated the likes of Dr. Martin Luther King Jr. I know he treats regular folks too. When your doctor gets a call stating that Senator Obama wants to come in to have something looked at, he initiates the VIP treatment sequence. He gives you your pick of times. He moves someone else if necessary. You will not have another patient scheduled immediately after you. He will not be pressed for time. He wont keep you waiting in his lobby for any length of time, and he will generally make you feel like you are his only patient. In short, your whole experience will be ideal in every way. The excellence in this healthcare situation has, at its core, focused individual attention on you, the patient.
If you are honest with yourself, I dont think you could possibly believe that giving every American access to the same health plan that you and senator McCain enjoy will really mean that all Americans will have access to the superb care that you enjoyed. I can promise you that the average citizen insured by Medicare or Medicaid who reads this letter will testify that their doctors visits are nothing like the scenario described above. Nor will they be if the average citizen is covered by the federal plan. The above example, however, is helpful. We have found the true root of excellence in healthcare: attentiveness to the individual. Thats what puts the good in good healthcare. Taking time give the patient individual attention and dignity is the main way for compassionately motivated doctors to distinguish themselves. Its what we all seek in a personal physician, or any other clinician. When the current US healthcare system has a shining moment, its the reason.
But individual attention isnt at all what the government does. In fact, the government isnt supposed to cater to individually to any one. Its practically unconstitutional. The governments role is to seek the best interest and the greater good for the populace. That will always be its motivating priority. This is the conflict of interest I referenced at the beginning of this letter. And when the government tries to apply its greater good motivation to a system that should focus on the individual good, the resulting compromise is a mess. Here is an example that well illustrates my point.
Last June, Barbara Wagner, an Oregonian, was denied access to doctor-prescribed chemotherapy by the Oregon Health Plan, because her prognosis was poor and the chemo was expensive in excess of $4000 per month. Instead, Ms. Wagner was offered access to state-sponsored doctor-assisted suicide. As you know, Oregon is the only state currently offering this service.
Thankfully, Ms. Wagner didnt take the states offer, and the pharmaceutical company provided her with the chemo pro-bono after learning of her plight. Ms. Wagners story makes us uncomfortable. Its cold and impersonal. If we look at the issue through the lens of government vs. healthcare priorities, it becomes apparent why. The Oregonian government was trying to do something which no government is equipped to do.
Governments are only equipped to address the needs of the greater good, and governments cant consider everyones individual circumstances. When government tries to make healthcare decisions about an individual using the greater good as a priority, we end up with chilling stories like Barbara Wagners.
To punctuate the example, please dont miss that the pharmaceutical company interceded to save the day. Its imperative to notice that as soon as the problem was apparent to the private health-care sector, even the commercialized pharmaceutical company couldnt keep from re-personalizing the situation to correct it.
This difference in priorities is the fundamental reason why your proposal for government run healthcare wont work. It will rely on government rationing to preserve the interests of the greater good. People in need will fall through the cracks. I might point out that in our present system nobody is turned away from an emergency room for lack of insurance coverage.
But you dont acknowledge this. Instead you have created a false dilemma. You have taken the large number of uninsured Americans, lumped them together, and put a label on them which reads, Cannot Access Healthcare. You tout the uninsured Americans as people who the system has failed, but this is untrue. The majority of the uninsured Americans included in your figures are healthy adults, usually younger adults, who choose not to purchase health insurance because their priorities are different.
For a healthy adult, private health insurance can be purchased under our current system, from a private vender, for just a few hundred dollars per month. This might sound expensive, but consider that the cost of a good policy is about same as a monthly cell phone bill plus two or three social evenings out. It becomes immediately clear that the vast majority of citizens included in your statistic could choose to make sacrifices which would then give enough money to purchase healthcare. I fall into this category, and I choose to have the cell phone and a social life, so I have no health insurance. Dont falsely label me as some victim. I take exception to it.
As you continue to push a overspending/entitlement agenda, consider this promise. If you continue to believe that you have the full faith of the overwhelming majority of Americans, I can assure you that you will not be re-elected in 2012. Be honest with yourself, and consider whether you truly believe that you could beat a hispanic republican candidate from California, Florida, or New York in 2012. Forget George Bushs public speaking skills or McCains patheticeverything. You will not be given an easy opponent in 2012, and the way things are going, there will be plenty wrong for him or her to point out.
I would be very interested to read your response to my criticism. I hope this finds you well.
San Diego, CA 92101