There’s an old phrase book for foreigners: English as she is spoken.

So let’s talk about Health Care rationing, as she is practiced.

With all this talk about government health care and the possibility that rationing will be part of the plan, I am astonished that no one has bothered to see how US Federal Government clinics and hospitals manage their limited health care dollars.

The government runs several medical systems. There is military health care, Federal Prison health care, The Veterans Administration health care, Federally funded community health care centers, and the Indian Health Service.

I worked for ten years in the IHS, so you might want to know about how they manage their budget.

The first problem is staff. How does one find physicians and other to work in isolated rural areas?

In the past, they drafted them, literally. When the US still had a draft, a physician could chose between going in the armed services or working at a federal clinic. Well, it was better than getting shot at. Later, scholarship students could pay off their loans working at these clinics, and many altruistic types tended to be attracted to the work, although many only lasted a few years. Finally, there was an active movement to train and recruit Native American health care workers.

Second problem: Facilities.

Usually these were bare but adequate. Thirty years ago, many were substandard, but since about 1990, there has been a lot of pressure to upgrade staff and extra funding to refer people for specialty care.

Third problem: Limited budget. This is where “health care rationing” come into play.

We could get nearly any medication that was needed to treat our patients, but referrals were the problem.  Not only was our budget limited, and the specialists with a long waiting list, but many of the clinics were so isolated that the clinics ran vans 200 miles so patients could see specialists.

Referrals were made depending on the urgency.

Class I, emergency, no problem.

If you had a heart attack, cancer, major trauma or another emergency, you were sent out and the bill was paid. We would even helicopter you out if you were critical.

Class II: Urgent.

For example, if your kidneys were failing and you needed to see a Nephrologist, or if you needed a follow up appointment for your chemotherapy, or if you broke your arm but it was splinted and couldn’t be set until the swelling went down, you are class II.

Our Obstetrics patients usually were followed by us until eight months, then transferred to the specialist, but their ultrasound (when we didn’t have a tech to run our machine) was class II.

Class III: Needs to be seen, but could wait.

If we were out of money, we might wait a week or two until funding was released to schedule the appointment, but it would be made.This group is what ordinary folks with chronic disease would fall into. They are cared for by the local doc, but need to have a specialist check them now and then.

This would include Cardiology appointments for our patients with bad hearts, or wound clinic appointments, or to see the Hematologist for anemia that wouldn’t improve. It also included tubal ligations.

Class VI. Elective treatment for disease

If your kid could use tubes for chronic ear infections, he would be here. So would your arthritic knee, unless it was so bad you had trouble walking. Chronic back pain, people with headaches that had already had a CT scan, or other diseases that were not life threatening, and where treatment was poor would be here.

If there was money left at the end of the month, and you were waiting, you’d get an appointment. If no, well the local doctors could care for you.

Class V: rarely funded. This included plastic surgery, fertility surgery, and  abortions. (Abortions were only funded if the child was deformed or the mother’s life was at risk.)

But specialty care that was needed often was handled in the system. And our clerks were good at getting alternative sources of funding, such as Medicare, Medicaid, free medicines from the drug company, and special funds for those who need care but aren’t eligible for other funding (we once did this to pay for a heart transplant on one young man).

I should not that some specialty care that we brought in was as good as you could get anywhere. Native Americans have a high rate of Diabetes, so we had extra clinics and diabetic nurse educators. We had podiatrists come up once a week to trim nails, so that the feet wouldn’t get infected from an accidental cut. And we had a surgeon from the University to come up and supervise a wound care project that cut our amputation rate to almost zero.

Since kidney failure from diabetes was alas common, most of the larger hospitals had their own dialysis units, which were usually run under the supervision of the local university Nephrologist.

So the good news: You get good basic medical care, and referral for most life threatening complications.

The bad news: The wait might be long, you might have to live with minor problems, the clinic is a dump, you can’t chose your physician (and might see a PA or Nurse practitioner instead of a physician), and the paper work for staff is atrocious, although the switch to electronic medical records might help this a bit.

Of course, one really doubts that any American health care plan would resemble the IHS, but I suspect that the “rationing” aspect might indeed resemble what one could expect.

My point is that this type of rationing can be lived with.

The real danger is if the “Peter Singer” or “N.I.C.E.” types take over, you could be denied treatment if it is too expensive, or your “quality of life” is low, and the treatment won’t make you normal, merely save your life so you can live while handicapped. I fear if these type inspire the funding bureaucracy, we too will see a point where “they” (an unseen clerk) will decide what treatment you get, and will deny funding for a lot of the diseases that are listed above as Class I or Class II.

Whose philosophy will be the basis of the Health care bill that is being rushed through the US Congress? One really would like to know…

Those of you who don’t read the literature in medical ethics might not be aware of it, but there are a lot of these S.O.B.’s writing about the need to stop medical treatment for those whose “quality of life” is low or limited (and to make things worse, a lot of them think legalizing euthanasia as an alternative is a good idea too).

If the President’s health care bill uses heartless “scientific” criteria to save money, expect an uproar that makes the “Teaparties” look like…tea parties.

This will simply not be tolerated by the American people. The Native Americans won’t tolerate it, the Black minorities won’t tolerate it, and the Christian Right to life types won’t tolerate it. Expect lawsuits to question the legality of such decisions.

To paraphrase Nat Hentoff’s comments on the now defunct Clinton health care project: Excuse me, but where in the US constitution does it allow the government to decide you can’t have medical care because it won’t improve your “quality of life” ?


Nancy Reyes is a retired physician living in the rural Philippines. Her webpage is Finest Kind Clinic and Fishmarket, and she writes medical essays at Hey Doc Xanga Blog.

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