Medical Care in Pt. Roberts

We are currently down in Bellingham pursuing a little medical care in the enormous medical complex that is housed there.  I'm used to being around hospitals, but that was two decades ago, and the changes in those intervening 20 years have been amazing.  There's the hospital and then there's dozens of buildings surrounding the hospital holding all kinds of specialized facilities, some belonging to the hospital, some not, but a place for every organ, every individual system, every conceivable need.

This stay at St. Joseph's (we're in to the 2nd day and Ed is the patient while I'm the family member) has been very good so far, given that one is dealing with a hospital.  We have no complaints whatsoever; although we might be unhappier if things weren't going well.  But it is reassuring to feel that, despite the isolation of Pt. Roberts, that there is good medical care accessible, although you do have an hour's drive to get to it.  But once you're here, you are here.

The other benefit we have come to more fully appreciate is the fact that Point Robert's Wellness Clinic provides not only initial wellness care but also, and even more important in this case, connection to physicians.  If it were up to us, I suspect, we might still be phoning around trying to get a physician to accept us as Medicare patients.  Or at the very least, trying to find one who would accept us and about whom we had any reason to feel confidence.  Virginia, the Saint of the Wellness Clinic, did that work for us.  And those who set the Clinic up originally had the foresight to make sure that that service was part of the foundation of the clinic. At least as far as I understand it, St. Joseph's-affiliated physicians are in some way obliged to accept referrals from the clinic.  We have surely had that be our experience, and are very grateful for it.

It's one thing to say that a hospital has to accept you in the Emergency Room, but they only have to do it until you are stabilized.  After that, you might well be on your own, even with insurance.  Having assured physician access means a lot.

End of the Year

End of the Year

The January All Point Bulletin is out with its recap of what we’ve all been through this past year in Point Roberts.  Although it's been a kind of crushing year for many, many people, the Point has come through pretty well, I’d think.  The library and the Parks Board got their levy increases, and there is a move afoot to try to encourage the County to do something about restoring the dock/boat launch at Light House Park.  All good things.  More of Lily Point was conserved and it appears that the historic remains will remain where they historically have been.  There have been deaths of course, perhaps most notably,  that of Irene Waters, but that is the truth of every year.  And we haven’t lost anything --other than dock and the curbside trash collection--that we formerly had, although one of the banks is looking a little poorly.

The newspaper also has a bunch of cheerful letters, thanking people for good things that came to pass recently.  And then, at the very end of this letter string, there is a downer:  a letter, initially about the Aydon Wellness Clinic, which the letter writer is hoping will soon go out of existence, because, apparently, it is a great burden on his existence.

Of course, many other people—probably most residents of Point Roberts-- find the clinic very helpful, find its staff knowledgeable and resourceful and able to get them to more complex health care when it is needed.  Thus, it’s a little hard to sympathize with whatever personal burden the letter writer feels about the clinic’s existence. 

Not content with hoping for the end of the clinic, the letter writer takes on health care reform as well, which he also hopes will go out of existence.  I spent a lot of years working in and around health care, so I’m pretty sympathetic to those who are frustrated with how the ‘system’ (or ‘no-system’) works.  But our letter writer’s grievance is largely that he is going to have to buy health insurance, even though he’d rather spend his money on gym membership and natural food supplements.  But he’s not going to buy health insurance, he says.

Well, I doubt if he’s discovered the secret of eternal life, either in gyms or health food stores or organic vegetables.  But I certainly hope that he’s willing to follow a life of true principle such that when and if he should experience the ominous chest pain that might precede a heart attack, or the strangely slurred speech that can appear as a sign of stroke, or the grievous loss of blood and the intense pain that can occur after, say  an accident involving cars or in homes with guns...well, I hope he proceeds immediately to his gym for a workout, or calls his health food store and asks which supplements can be delivered to him ASAP.  The unprincipled alternative, of course, would be to get himself to a hospital, where the rest of us will have to pay his bill.

Flu: Not for All

Having pointed out only a few days ago how well the All Point Bulletin informs and reflects the Point Roberts community, I return from the Sunshine Coast today to find the November issue of the paper with the following headline:  ‘County Hogs First Supplies of Vaccine’.

So, what does that say about us?  Well, first of all, that we are very plain-spoken and perhaps even outspoken.  Second, that we are a little on the cranky side.  Third, that we may be a little confused in our irritation.   Exactly who is the ‘County’ that is hogging the flu vaccine?  I mean, aren’t we part of the county, of Whatcom County?  I can imagine the county might be refusing to let people from other counties come to their vaccine clinics, which would, of course, allow Skagit County residents to complain that Whatcom County is hogging all their vaccine for their own residents.  But the paper, if it speaks for us, seems to be complaining that those of us in Point Roberts aren’t getting our fair share of the Whatcom County vaccine supply. 

Join the nation! You can’t turn on any public radio station or otherwise talky radio without hearing people complaining about and/or explaining the insufficient availability of H1N1 vaccine.  We are ALL being deprived, apparently.  Says our local health clinic head, ‘When we get it, you’ll get it.’  Which is what health clinics are saying everywhere.  But somehow, I guess, anybody who wants to have the vaccine today and who isn’t getting it is entitled to be outraged about their fair share of health resources, even if they aren’t people who are considered priority for the service in question.

As near as I can tell from reading the article, in Point Roberts, there is some concern that seniors are being denied access to the vaccine.  Like a death panel deal, I guess.  But seniors, unless they have other very serious conditions, aren’t the clientele for this vaccine.  Perhaps all the years of trying to make all seniors take the regular flu shots has simply convinced people that flu and seniors are inextricably connected.  I rejoice that I am not expected to have one of these shots.  Point Roberts’ larger senior community could well be rejoicing with me rather than feeling victims of ‘The County.’

So, there we are: plainspoken, outspoken, cranky, and confused.  My Point Roberts.

Healthcare Reform

I spent about 20 adult years working in and around health care and healthcare policy as a bioethics teacher.  As a result, little in the current effort to reform something in healthcare and healthcare access (it’s not always clear which one is under discussion) has been a surprise to me.  Twenty years ago, discussions about rationing care, including expensive technology, were perfectly ordinary stuff including rationing that might lead to individual deaths.  We didn’t need Sara Palin to tell us about this possibility because we’d already had that happen with kidney dialysis and the infamous ‘God Committees’ in Seattle. 

But we also talked about things like how justice was served by ensuring that only one disease had treatment costs guaranteed (kidney failure)?  While people with other diseases were out of luck?  The story of how dialysis costs were covered under Medicare, even if the patients were not over the age of 65 was one of the basic stories my co-author and I covered in our 1986 book, Choosing Life or Death, a book for the general public about contemporary legal and ethical issues in healthcare.  (1986).  (A patient who would die without dialysis was wheeled onto the floor of the House of Representatives during the discussion of this healthcare bill.  That got results.)

Anyway, the health insurance debate if not giving me new information has surely been depressing as to effect.  It is indeed hard to think of the U.S. as an important, powerful country when it can’t get even policy as basic as healthcare competently structured.  More expensive, worse outcomes, and little evidence of effectiveness is the diagnosis, and the treatment is that everybody really needs to buy insurance.  Yikes.

Well, in the midst of all this, I had my own insurance experience that did surprise me.  I worked at UCLA and while I was there and since I retired (some 35 years total), I have had dental insurance from UC which the University pays for.  And it works okay even up here in Point Roberts where I routinely go to Canadian dentists.  The tooth numbers are different, the procedure codes are different, the currency is different, but eventually things get worked out, although I almost always have to have some additional interchange with them about whether they are going to pay.  I am helped by an earlier court case that required them to pay in a timely manner or add interest to the payment.  Delta Dental is the insurer.

Unfortunately, this spring, I had a tooth whose root cracked.  It had to be extracted and a permanent bridge installed to fill the space.  Expensive, but on the other hand, I have insurance.  Imagine my surprise when the insurance company refused to cover part of the procedure.  I thought it was the regular deal where they say no and i say yes and then they say okay or take half, or whatever.  The total cost of all this was to be around $3500, and I’d pay about half of it under the terms of the insurance.

But, no.  They refused part of the claim because I had ‘exceeded the maximum.’  Only at that point did I discover that for all those past years, UC has been paying about $500/year for me to have dental insurance whose maximum yearly payout is $1500.  (If I had stayed in California, the insurance would have no payout limit.)   This is remarkably like the Social Security Drug Insurance with the infamous ‘doughnut hole,’ except in this case, there is no doughnut, just a hole.  If you need help with a high-cost procedure, the insurance company says, ‘not our responsibility; our responsibility is the low cost stuff you could pay for yourself.’

The essential idea of insurance is that you pay to cover costs for something that has a low risk of happening but a high impact because of the likely high costs of the event.  $500 a year for a $1500 risk.  Just nuts.  Just right for another cog in the U.S. healthcare not-a-system.

Emergency?

One of the questions my friends from away most frequently ask is what we do up here for medical services. I had a few days ago a (very minor) experience in that question. It illustrates both the problems of rural life medical care and of lack of health insurance anywhere.

Thursday evening, while fixing dinner, I cut a slice off the right-hand side of my left-hand index finger. Because it was bleeding so profusely, I couldn’t really tell how much of an injury it was, but I wrapped it tightly in a strip of muslin in order to apply adequate pressure to stop the bleeding. As long as the pressure was exerted, there was no bleeding, But the minute I stopped, it went back to bleeding. It wasn’t spurting blood; just flowing freely from the cut tissue. What to do?

I am in Canada at the moment, and there is a nearby hospital with an E.R. open at night if I need it. If this had happened when I lived in L.A., I would have thought nothing of driving over to my HMO ER to get their view of what, if anything, needed to be done (specifically, suturing). And they would probably have put in a few stitches because, since I’m already there, why not? But I have no HMO to go to now. But if I go to the Canadian ER, they will charge me around $500 for treatment. I know this because Ed had a similarly-placed but more obviously–in-need-of-suturing injury a couple of years ago and that was the price, plus $400 for a bandage change the next day. What to do?

I got out my book of home care (provided to me by my former HMO) which is very helpful in such instances. On the relevant page, it gave me about 6 indications for seeking medical care with cutting injuries and I was okay on 5 of the 6, I thought (although I really didn’t know the depth of the cut), but not so okay with #6, getting the bleeding stopped. What to do? I thought about the $500. Medicare of course won’t pay for out of country treatment. (Medicare’s view is that if you are old, you should stay inside the country.) My secondary insurer would cover 80% of the cost, but of course I would have to get them to do it, which is likely to be an unhappy though eventually successful piece of work. But it isn’t just the money; or it is, but not my paying for it. It is that I feel very strongly about not using medical care if it’s not really necessary. And I don’t know whether it’s necessary in this case. But I do know that the research shows that when patients judge whether care is necessary, they’re as likely to go without care they need as without care they don’t need.

Had I been in Point Roberts, it would have been much the same problem. If stitches are to be effective, they must be done within 8 hours, says the home care book. And I had no access to anyone in P.R. at that time of night+8 hours. (During three days of the week during the daytime, there is a clinic that would have been a simple answer, however. Lesson? Use knives only during daylight hours on the days the clinic is open.) I could go over the border (a 15-minute drive at most) to the E.R. there, but that solves no problem, because I’d be back at the Canadian ER charges for non-Canadians. I would have had to drive an hour each way to a Bellingham (U.S.) hospital and wait several hours once there probably but, because I’d be a Medicare patient, they would be likely to tell me I didn’t need stitches if that were marginally the case, because the Medicare reimbursement is very low.

Left on my own (and with Ed, of course) to decide, I went for more dedicated efforts to stop the bleeding and was, eventually, more or less successful. Enough to decide to let the rest of the 8 hours lapse, which ended the decision period. So that’s how we deal with health care up here. I think that my mother (born in 1911) and my grandmother (born in 1888) would both have known right away what to do and, if it needed stitches, could probably have done the sewing themselves. But we’ve lost that kind of knowledge now. And that’s one of the reasons our health care costs so much.

Speak, Obama

Well, we’ve gotten to and almost through this day and a good thing to have done so. About the only thing that is a matter of public policy that I know a lot about is health care and so, in honor of the new President, I’d like to offer him the speech that I wish he’d give on health care.

‘My Fellow Citizens and Health Care Users,

There are many difficult problems facing us all--and especially me--today, but fortunately, there is one problem whose solution is clear. It is clear because we have a lot of experience, a lot of research, a lot of history, and a lot of examples from other countries. In fact, it is hard to think of any other policy discussion where there is so little disagreement among those who have seriously looked at the issue as to what needs to be done. And that is health care.

The health care system we want should be efficient, equitable, effective, and affordable. To achieve that requires that everyone be in the system and that there be a single payer. That is a simple truth, though what some might consider an inconvenient truth. A single payer system is required because if there are multiple payers (as in multiple insurance companies), those companies will be compelled to try to provide insurance for people who are healthy, and deny insurance, coverage, and reimbursement to people who are sick. That is the nature of insurance. If you are ensuring health care, however, you cannot have multiple payers competing for patients on the basis of price and health-risk.



The system that my administration and the Congress will be working on is not a universal, single-payer system, however. Americans can not have the best health care system, one that works for everyone now and in the long run, for two reasons. First, because the Congress and I cannot stand up to the power of the health care industry; and, second, because many of you fear change, and fear that if something is different, it might be bad.

So, if you want a system that is able to control costs, that is able to include everyone, that will be available to you when you need it without bankrupting you, that will be a background not a foreground issue in all your life decisions, then you will have to demand from your legislators a national, single-payer health care program, and you will have to prepare yourselves for change. Otherwise, you’re going to get stuck with what you already have, and with its getting worse as the years go by, even while we tinker with it.

The choice is yours. Make us do the right thing.”

[I was inspired to write this by an article in the February 2009 Harper’s by Luke Mitchell, which explains the issue much more expansively.]

How You Feeling?

An interlude with the dentist reminds me of the question people who don’t live in Point Roberts often ask me about Point Roberts. Specifically, “What do you do for health care?” Good question. As one can imagine, the almost 4-square-mile peninsula does not have an HMO, a hospital, an ER, a fully-staffed clinic, or even a doc-in-a-box, let alone a dentist. There’s no home health care business, no hospice program, and no pharmacy. The International Market does carry a respectable but limited supply of over-the-counter medicines, so we are never deprived of, say, aspirin. In a sense, you are unusually on your own, so mostly, I think, we try to stay well.

When we moved here, the options were either try out the Canadian practitioners who are just minutes across the border or drive to Blaine/Bellingham, either of which has its problems, although I did try the Canadians who, I found, had special prices for Americans. But when we moved here, we were still also living in Los Angeles, so we pretty much waited until we went down there, even for emergencies, as it turned out. Once the L.A. part was over, though, we somewhat incorporated ourselves into what is here. Canada has dentists and their charges and services are pretty comparable to the U.S. (especially now that the exchange rate makes the two dollars about even). My U.S. dental insurance pays for Canadian care, although it doesn’t do it at a very rapid rate which, I assume is a result of their having to figure out the exchange rates.

Medical care: a little more complicated. About five years ago, Point Roberts managed to put together a special, targeted tax increase that funded a local clinic—the Aydon Wellness Clinic, pictured above--and staffed by a nurse-practitioner. It is also connected in some way with a Bellingham hospital, so you can get a referral to docs who practice at that hospital. Bellingham is about an hour’s drive away assuming the border crossing is minimal time. The nurse-practitioner’s husband happens to have laboratory tech experience and so he does some of that work here, as well. The clinic is good for simple ‘emergencies.’ You run a nail into your foot; you can get a tetanus shot. You fall off your deck (as I did), and the nurse-practitioner can tell you whether you need to go to an ER or just go home and lie down with an ice pack. Routine monitoring for chronic conditions is available there, as are routine tests, immunizations, injections, and other stuff common to routine general medical practice. However, it’s open only three days a week. And the NP and lab tech husband are a special combination of service-providers, not likely to be duplicated. Furthermore, they were already retired and living in Point Roberts. If they quit (by choice or by inevitability), not clear whether they could be easily replaced.

Thus, one is still dependent on some other medical system. People often comment that it would be good if we had a doctor here, but we did once and it didn’t work out at all. Maybe eight years ago, a Canadian M.D. managed to get himself licensed in the U.S. and procured a green card and set up shop in Point Roberts. But there wasn’t enough clientele to keep him occupied. I think that’s ultimately because people aren’t looking for a doctor here now: they’re wishing there had been one here a long time back so that he/she would already be their doctor. After all, one makes some accommodation to the system you live with and starting up with a new doctor is a big psychological investment. Maybe he won’t stay; maybe you won’t like him; maybe you’d better hang on to whatever doctor-connection you’ve already made, even if it’s inconvenient.

A few years later, the B.C. insurance company that provides malpractice for B.C. physicians announced that it would no longer include in that coverage care provided to Americans. Later, the insurance company said it would make an exception for Americans living in Point Roberts, which was nice, but a strange business decision that I wouldn’t want to rely on if I were a Canadian doc. Medicare is said to cover costs of care in a Canadian hospital if it is closer than the nearest American hospital and if you are not in Canada on vacation. That is, the Canadian hospital must be nearer to where you live than the closest American hospital is to where you live. I looked it up in the Medicare regulations and wrote down the regulation section number in case I ever needed it. I suspect that, like the dental insurance reimbursement, that check will not be quick in arriving in my mailbox, though.

A commitment to Christian Science or exclusively to alternative medicine is probably the best answer to health care in Point Roberts. Or maybe just a strict regimen of daily exercise, no smoking, moderate alcohol use, and balanced and moderate meals, plus no prior medical conditions. Hard to know which one to choose

Enhancing Canadian Healthcare

When you come to a second country late in life, there’s always more to learn and everything you think you know is probably not quite right. Canadian healthcare, for example. I spent a couple of decades working in U.S. healthcare (as an academic, not as a clinician), and the comparison point was often Canadian healthcare, so I came to Canada thinking I understood it pretty well. And the irony of the fact that I couldn’t actually emigrate to Canada was because of Canadian healthcare was definitely not lost on me. But I’ve used Canadian health services and I know a few doctors and nurses who are Canadian practitioners so I thought I sort of understood it as well as a foreigner is likely to.

Nevertheless, I was surprised to receive a brochure in my Canadian mailbox the other day urging me to buy a healthcare insurance policy from something called Pacific Blue Cross. It pointed out that ‘the time to obtain health coverage is before unexpected medical expenses occur,’ and further inquired: ‘Shouldn’t we be more concerned with our health?’ I have no easy answer for that latter question, but I was surprised to think that Canadians needed to buy health insurance, other than for travel to other countries, which the Canadians I know routinely do buy. In fact, other than travel medical insurance, I was surprised to find that anybody was even selling healthcare insurance to Canadians.

But they are because, although Canadians all receive healthcare through their provincial medical plans, the provincial program (as Pacific Blue Cross points out on its web site) covers only basic things like physician visits and hospital care. Only? Basic? Aha, I said to myself. That’s what happens when you have national health insurance. People start longing for other kinds of things to be paid for by the unknown someone elses that constitute insurance pools.

What Pacific Blue Cross is offering is coverage for those ‘other ‘ things, including ‘essential and enhanced dental care.’ Enhanced dental care would be what? Apparently non-essential dental care. Including ‘vision care, physiotherapy and massage therapy, chiropractor, accidental death or dismemberment, hearing aids, hospital daily cash, emergency ambulance, prescription drugs, and out of country travel insurance.'’ Now, the standard healthcare system covers some of those things in the course of ‘medical necessity.’ For example, annual vision exams are covered for older people, but not for everybody else because there is no evidence that doing so would improve healthcare outcomes and thus they are not medically necessary.

Other things, I wasn’t so clear about, so I inquired of Canadians. It turns out that one problem they see in their healthcare is that the provincial plans actually differ as to what is covered beyond those basic doctor visits and hospital stays. Thus, I am told, an emergency ambulance might cost $50 in one province and $100 in another, but if you are in a province other than your own residence when you need an ambulance, it might cost you instead $500 (the solution to this, of course is either enhanced insurance or staying home). Some provinces may cover some kinds of physiotherapy, others may not. Prescription drugs are cheaper than in the U.S., but Canadians still pay for them, whatever their cost, and they can be very expensive in some cases. (In fact, around 2/3 of Pacific Blue Cross’ payout is for prescription drugs.) Dental care is not part of national health care at all. Further, if you are covered at one level by one province and you move to another province, your coverage changes. Finally, people whose participation in national healthcare is ensured through their employer may have different levels of coverage beyond the basic program, depending upon what the employer is offering as the enhancement package from an insurer like Pacific Blue Cross. By contrast, people who obtain their participation in national healthcare individually because they are not employed receive only the ‘basic level,’ for which they pay a relatively small quarterly payment. One person I asked who received care in this way couldn’t remember how much she paid quarterly, so it can’t be too much.

So that’s today’s education for me on Canadian healthcare. The ‘hospital daily cash’ I’m still not clear on (although Ed refers to it as ‘hospital walking around money,’ in tribute to the U.S. political season), and the ‘accidental death or dismemberment’ as a function of healthcare services entirely escapes me. At least I am pretty certain that if one is accidentally dead or dismembered, it is definitely too late to ‘be more concerned with [one’s] health.’

How Are You Feeling? Healthy? Safe?

Canada believes that Canadians have a right to appropriate healthcare and thus the government’s job is to ensure that that happens. By contrast, the U.S. government believes that healthcare is a very good thing and that it would be a very good thing for all Americans to have it, but it is willing to make sure that they have it only if they are poor and have young children, if they are old, if they are disabled, if they are current or former members of the military, or if they are employees of the U.S. government. That, in terms of spending anyway, gets us about half way--sort of--to where Canada already is.

And even those Americans who do have this access to healthcare have it only within certain limitations. For example, if you are old, you have to pay 20% of your healthcare costs up to a total of a gazillion dollars. Under U.S. Medicare, there is no limit on out-of-pocket expenses which, if you are very sick, can require you to have very large pockets indeed. In Canada, by contrast, people go to the doctor when they need to, and they get the care that is needed, and their payments are very, very small. E.g., my friend who is an asthmatic pays no fee to see her doctor and $10 for the asthma inhaler that she uses regularly. If I go to her Canadian doctor in a non-emergency situation, I will pay, as an American, a fee in the range of $40 (last time I went, anyway) and the asthma inhaler will cost me about $30. Social security will not reimburse me, of course, even though my closest Canadian doctor is two miles away and my closest American doctor is more like 35 miles away (plus an extra border crossing). And both services would cost more in the U.S.

There is always a great to-do in the American press about how Canadians have to wait for services. In my observation, the waiting is not as great as the papers make it out to be (and there are different waiting levels in different provinces and in different parts of each province, and I only see the very southwestern part of B.C., and not much of that). And I haven’t noticed that it’s particularly easy to get into a U.S. doctor’s office without a considerable wait. My Canadian neighbor suffered a sudden-onset viral encephalitis, was air-evacuated to Vancouver, spent 6 weeks in a neurological ICU, 4 weeks in a ICU stepdown unit, and another 2 months in rehab at no cost to him or his family. And without waiting for services, although he did have to go to a rehab unit that was not close to his home. But then he also had to go to a hospital that was not close to his home. That’s what happens when you live in a rural area.

Having had some experience with both systems, I can only say that I don't have a second’s hesitation preferring the Canadian to the American system. Both systems are in trouble now because of the financial pressures, but that is not a fault of the system aspect of the Canadian system. Both systems are suffering, largely, from the fact that we have as North Americans been indoctrinated to believe that only if people have constant use of (as opposed to universal access to) healthcare services can they possibly expect to stay alive, so in both countries, services are overused. But they are considerably more overused in the U.S. (A terrific little essay on this that appeared a couple of days after I wrote this post: http://www.washingtonpost.com/wp-dyn/content/article/2008/03/28/AR2008032802972.html?hpid=opinionsbox1

The story of healthcare in both countries is a long and complicated one, and I can’t do much in just a few paragraphs to elucidate it. But there is this one strange fact that stays with me. The Canadian healthcare system came to be because of the deeply-felt commitment of a politician named Tommy Douglas. Douglas was the Premier of Saskatchewan, a member of the party that eventually became the (far left) New Democratic Party, and he brought single-payer, universal healthcare to that province, and he continued working to extend it to everyone in Canada, and he was successful. He died in 1986, living long enough to actually see the fruits of his labors.

So that was what he gave to Canada. And what did Tommy Douglas give to the United States? Something you might think almost as important given the frequency with which I hear people telling me about the cultural and political importance of the TV show ’24 Hours.’ Tommy Douglas is Kiefer Sutherland’s grandfather, and Kiefer Sutherland, of course, is Jack Bauer, who every week has to torture bad guys to keep America safe. They get healthcare; we get torture. This does not sound like a bargain to me. Well, certainly living well is the best revenge; but Douglas may have done that one better.