As I See It

A Defining Moment for Health Care

We can't reform health care until we agree on what it actually is.

By Paul S. Koch, M.D., Editor Emeritus

No good ever comes from getting embroiled in a conversation about religion or politics, and it is something I avoid with the intensity I devote to vegetables. Why work your way through a bowl of steaming greens when for the same effort you can have a helping of macaroni?

Even so, I cannot help but be drawn into our national debate about changing our health care system. Readers new to this column do not yet know what the long-timers do: that I truly am perhaps the dullest knife in the drawer, the dimmest bulb in the socket, and I did indeed just fall off the turnip truck.

And so, when I read each day about the plans for revising the health care system in America — touted as "reform" by its proponents and thus expected to be improvement — I am more easily confused than the average person. After following this for a month and reading about the need to pass legislation quickly, I still cannot figure out what it is that they want to pass. Are there specific proposals to be studied, or only speeches about the need to pass something?

Still, the flurry of activity suggests that apparently we simply must, and right away, pass it — pass something, anything, to provide health care for the uninsured, except that many still won't be insured, and it must be paid by taxing businesses struggling in this recession, surely not a prescription for long-term health cost viability.

But I am a fool, so I ask a foolish and basic question: "What do you mean by 'health care'? What is your definition?"

Where to Draw the Line?

When referring to health care, are you talking about catastrophic coverage in case of cancer or stroke? Or are you taking about every doctor encounter — a meeting with a highly skilled professional currently costing you a co-pay roughly equal to a pair of movie tickets?

Are you talking about mental health coverage? If so, are you including depression from sexual inadequacy in the middle-aged male? Do you plan to pay for pills for enhanced performance to restore self-esteem? If so, what about the female with feelings of inadequacy because of hypoboobia? Shall we pay taxes so she can have implants? I'm very happy to contribute; I just want to know.

Are you talking about dental coverage? Does that include whitening treatments and dental implants?

What about fertility? How many times? For how many kids?

What about the last days of life? When the family storms the ER and demands we keep mom alive, and that cost is no object, do we say, "It sure as heck is, buster" and suggest that perhaps it's time to buy that black suit?

What about cataract surgery? Will we fix one eye so mom isn't blind and that's it? Will there be a visual acuity cut-off, with no allowance for contrast sensitivity or glare?

And, hold your breath, here it comes (wait, don�t say it, ohmygosh he's going to say it! Oh no, stop!) — what about abortion on demand? Will the government be making everyone pay for this, including those with passionate faith-based opposition?

Don't Ask, Don't Tell

It seems to me that we cannot be discussing changing the health care system until we agree on what is meant by "the health care system." It also seems to me that we cannot be talking about how much it will cost and how to pay for it until we know what we will be paying for. It further seems to me that medical professionals cannot be for it or against it until we know how it will affect our ability to care for patients.

Alas, the would-be reformers seem to have a "don't ask, don't tell" policy about what they're trying to reform.

Sorry for being cantankerous, but it seems to me basic: define the problem before trying a fix. It's the swamp yankee in me. OM

Paul S. Koch, M.D. is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, R.I. His e-mail is: paulkoch@kocheye.com.