Healthcare Reform

The clinical function of the Johnson Health Center is to be the primary care provider for the uninsured and under-insured of Lynchburg city and surrounding counties.  Having a primary care provider relieves the medical burden on local hospital emergency departments.  In fulfilling this function, one of the bigger challenges in Community Health Center medicine is reconciling patient expectation with available medical resources.  The American healthcare system has conditioned patients to expect perfect babies, perfect surgical outcomes, and prescription medication on-demand – with NO out-of-pocket expense!  I recently de-escalated an enraged patient that would not pay a one-dollar co-pay for a necessary medication.  I know of no other field that such standards apply.  The entitlement attitude of the American patient has driven a market that is unsustainable.  Legislation will not change this attitude.  

When the American Colonies rallied around a call for independence following the Stamp Act of 1765, I dare say that colonist, at the time, thought legislation would fix King George too.  The first Continental Congress met at Carpenter’s Hall in Philadelphia September 5, 1774, following the British naval blockade of Boston Harbor in 1773.  The colonial delegates initially were not ready to abandon ties to Britain, and despite Colonial Militia exchanging fire with British troops at Lexington and Concord in April 1775, continued to plead for Parliament to end hostilities.  When King George declared the Continental Congress traitors to the Crown, the American Colonies declared themselves a sovereign nation on July 4, 1776.  The rest is history.

Now, almost 236 years later, medicine in the United States faces a similar legislative upheaval, with the passing of the Patient Protection and Affordable Care Act March 23, 2010, by the 111th Congress.  As provisions in the law continue to be debated, Community Health Centers face the biggest challenge ever to remain clinically relevant and publically valuable.  While certainly not alone, Community Health Centers bear a sizable burden of the care for the medically uninsured and under-insured, begging the question: To what services should all people have access, and therefore, be guaranteed by government funding?  Anyone can see the economy and moral imperative to provide pregnancy prenatal care and well child care.  Conversely, anyone can imagine the economic insolvency of mandating various elective procedures.  However, who is going to tell the couple of a 24-week premature infant that their child is too costly for neonatal intensive care, or that the obese smoker doesn’t deserve cardiac rehabilitation, or that Grandmother is just too old to justify a hip replacement?

The debate puts Community Health Centers on the front line between the American free market and collective health of its citizens.  Regardless of what legal decisions are made with healthcare, medical providers are going to have to make the policy work in everyday life.  My colleagues and I frequently ask how we are going to absorb this influx of the newly “insured?  Will healthcare reform give us more or less power to make clinical decisions? With a shortage of primary care physicians, will the current network of providers be able to handle the load? Will healthcare reform end our nightmare of sitting in an exam room and explaining to a patient, that the decision to order their C.A.T. scan for a pelvic mass, or their progesterone injections for preterm labor, or their hysterectomy for fibroids, is lost in the Bermuda Triangle of “pre-authorization.”

Working at a Community Health Center may not be the most glamorous job, but it is certainly where the action is.  Our work hours are maxed out with increased patient load, more administrative responsibilities, and growing regulatory requirements.  It is obvious to any doctor that quality accessible medical care cannot be legislated.  Healthcare reform must start with the public in general accepting personal responsibility for unhealthy life choices, realizing that a healthy mind and body is hard work, not an entitlement, and acknowledging that a person’s medical provider is that best qualified to make their medical decisions.  With an enlightened public, rebuilding our medical infrastructure with passionate and qualified primary-care providers, given the autonomy to make medical decisions, freed from the fear of frivolous malpractice suits, and governed by non-conflicted regulatory boards, will fix healthcare – for our children’s children.  As healthcare reform unfolds, medical providers in Health Centers around the country are likely to shape the future of primary care medicine for generations to come.