Wednesday, April 29, 2009

Free Universal Health Care

From Alexanr Solzhenitsyn's The Cancer Ward, describing a discussion in a remote Russian province in the mid-1950's. In the chapter "The Old Doctor," the retired Dr. Oreshchenkov speaks at length to one of his former students, now a senior doctor herself. The quote starts with her reply.
"That's all very well, but how many family doctors would you need? It simply doesn't fit into the system universal health service."

"It'll fit into a universal national health service, but it won't fit into a free health service," said Oreshchenkov, rumbling on and clinging confidently to his point.

"But it's our greatest achievement, the fact that it's a free service."

"Is this in fact such a great achievement? What does 'free' mean? The doctors don't work for nothing, you know. It only means they get paid out of the national budget and the budget is supported by patients. It isn't free treatment, it's depersonalized treatment. If the patient kept the money that pays for his treatments, he would have turned the ten roubles he has to spend at the doctor's over and over in his hands. He could go to the doctor five times over if he really needed to."

"But he wouldn't be able to afford it?"

"He would say, 'To hell with the new drapes and spare pair of shoes. What's the use of them if I'm not healthy?' Is it any better as things are now? You would be ready to pay goodness knows how much for a decent reception at the doctor's but there's no one to go to get it. They all have their schedules and their quotas, and so it's 'Next patient, please.' As for the clinics that do charge fees, the turnover's even faster than the others. Why do people go there? Because they want a chit or certificate or sick leave or an invalid's pension card. The doctor's job is to catch the malingerers; patients and doctors are like enemies. Do you call that medicine? Or take actual drugs and medicine, for instance. In the twenties all medicines were free. Do you remember?"

"Is that right? Yes, I think they were. One forgets."

"You'd really forgotten had you? They were all free of charge, but we had to give it up. Do you know why?"

"I suppose it must have been too expensive for the government," said Dontsova with an effort, closing her eyes for a short while.

"It wasn't only that, it was also that it was extremely wasteful. The patient was bound to grab all the drugs he could since they cost him nothing and as a result he threw half of them away. Of course I'm not saying all treatments should be paid for by the patient. It's the primary treatment that ought to be."

As the number of PCP's needed is a current issue as well, I thought it apropos.

It is also a proposal that is not even on our health-care map: that the patient pays for primary care and medicines, but hospital and specialist services are paid for by the government.


Terro said...

Wow...a great illustration of truth in literature. Thanks for bringing it to my notice. I'm going to include a link on my blog.

Retriever said...

Good. Fantastic quote. And I agree with it. Our family spends over half our only salary (mine) on the copays and deductibles for the good private health care that my insurance only partially pays for but that keeps everyone functioning and reasonably productive. Better that than free cruddy care.

But noone that I know of (even the shrink blogs) has yet tried to propose a way to pay for the care of the chronically mentally ill. Especially, the walking wounded who are able to work, but who cannot afford the care (or the meds, sometimes running to a $1000 a month per person, and since mental illness is genetic, sometimes 2 or 3 people in a family needing them) that will keep them well enough to support themselves.

Also, in my state at least, there is a huge gap in coverage for those who are not "disabled" or "retarded" but whose conditions and/or social oddities make it impossible for them to get or keep work. I am thinking specifically how on earth my high functioning autistic/bipolar kid will support himself and get medical care after he ages out of my health insurance, and after we die.

Obviously, families do what they can, but what happens when the exhausted parents die or get sick? Mental health care is more expensive than most other forms of treatment, and yet because mental illness is stigmatized people can rarely lobby for it (if they hope to remain employed)

Donna B. said...

Retriever makes good points. I have a son in his 30s who suffered a severe closed head injury at age 7. His survival is a miracle, but his continuing medical needs are a nightmare.

It needs to be realized that our ability to save lives does not necessarily include an ability to make those lives "productive".