So what's going to happen to health care now?

Susie2310 · Mar 1, 2017

I think it is also important to look a little bit closer about what is going on with our healthcare system and the care that is "available" in the US.
Somebody mentioned that instead of offering "something" or "basic coverage" to everybody - wouldn't you want the best and most comprehensive care and treatment options?
It is worth looking more at it - I have heard this a lot during the last years. I grew up in a country that has a very comprehensive social system including healthcare - which is mandatory and "expensive" compared to what a person pays in the US.
From working many years in hospitals and also in the community, I can say that the way people approach healthcare or the way money is spend does not automatically result in something "meaningful" or a high quality of care. Obviously, there is a difference between spending money on healthcare that is preventative or for illness that can and should be treated and spending money on trying to "fix" something that is not fixable with a questionable quality of life.
And I also question the admission of the 90+ person with dementia and several other comorbs who now has another pneumonia to an ICU to receive very expensive treatment for something that cannot be fixed.
When people ask for "more and better" options and healthcare - what do they actually mean?
The US is doing good with cancer care and treatments in terms of survival - this is all very expensive care.
There is an underlying false belief that medical science can "fix anything and everything", that "miracles happen when you fight hard enough" and "do not give up" and that we "can cure everything nowadays". I am not sure when that idea started but it is very prevalent now and not rooted in any reality. That goes hand in hand with putting more value on the "time to live" as opposed to "quality of time" especially when we get to the higher age and multiple illnesses.
People are not that willing to accept a physician's recommendation or accept their level of expertise anymore. Not that long ago I was a witness of a conversation between a surgeon and a family in which the surgeon told the family that based on high age, severe illness with multiple comorbidities and low functional status he recommended to proceed with comfort measures and not to do surgery for another new issue as this surgery would be very high risk. He was clear in saying that there is no way the patient will survive one way or another and even if surviving surgery would be depending on a ventilator and most likely die of other problems related to the post operative stay.
He was very clear and talked with great empathy. Guess what - the family insists on the patient being a fighter and wants to give the patient a chance. When I asked if they understood the implications and tried to explore further what "a chance" means there was no answer to it.
So why are people not ready to let go and even consider treatment that boarders on futility?
US Spends More on Health Care Than Other High-Income Nations But Has Lower Life Expectancy, Worse Health - The Commonwealth Fund
U.S. Health Care from a Global Perspective - The Commonwealth Fund
I am a strong advocate of providing a basic healthcare to everybody and I am also a strong advocate for not throwing money out of the window so to speak. Avoidable re-admissions, "last ditch efforts" to "fix" something that can't be fixed, and admissions to the hospital because people do not want to pay for custodial care (nursing home longterm care) and come up with all kind of medical complains to get their loved one admitted is not on my list of things I support.
For sure we need some discussions in our country about healthcare and why we spend all this money with a comparable worse health looking at other developed countries. One rising problem is that Medicare skilled nursing in nursing homes (short term "rehab") is used in excess for people who actually need longterm care. Those folks want to be at home, typically have not much or no family support ("they all work", or "nobody lives close and they have their own life") and their families or spouses try to keep them at home but are unable to provide the care. My favorite is the "altered mental status" complaint of the person with dementia who is in an advanced stage and needs 24/7 attendance and care - who is not able to swallow much anymore and continues to aspirate. They get admitted for "something" because there is always something not ok for sure - including acute renal failure due to dehydration, which is often a natural consequence of the illness. Now we hydrate the heck out of those folks who also have a weak heart and push them into CHF. While the family marvels over "I knew something is wrong and hydration always makes him better" instead of " I get it - the dementia is endstage and a terminal illness - this is not really fixable." Ok - that person eventually will leave to "rehab" but of course only for very short time - they are unable to really rehab. They get discharged back home, where after days or weeks the caregiver calls 911 again with complains of "confusion" and the circle continues.
Our country is set up in a very strange way - people who have nothing not much qualify for Medicaid, which will pay for longterm care when they need it due to illness - but Medicare will not. Some people have longterm care insurance but most people do not have that kind of insurance. When Medicaid pays for family to be a "paid caregiver" that can result in other problems including "keeping somebody alive" and pushing for treatments that are close to futility as this is the main income.
Our society that also lives on litigation also drives all kind of costs as physicians will order all kind of tests and images to make "double sure" and will offer treatments or options that make no sense to a person with common sense. Of course patients and families will grab the straw...
Physicians who should have discussions in the community about what happens when you have dementia, end-stage CHF, end-stage liver disease, endstage metastatic disease and so on and who do not talk to their patients or families are also at fault. I have been talking to a lot of families who are really surprised to learn that dementia is still terminal and progresses with problems swallowing that leads to other problems like pneumonia and dehydration. Of course why would they believe the hospital staff after the PCP has not mentioned it for the last 10 years???
Or the oncologist who really cannot face another discussion in which he has to say that there are no options left that would result in something meaningful and who instead gives this vague message of "you do not need to come back to my office but there might be a new treatment right around the corner" indicating the chance of the miracle cure that might happen tomorrow - of course people want to hear that. They do not want to hear that medicine cannot cure everything ad the medicine / technology as limitations.

You have these concerns as a nurse, as many nurses, physicians, and other health care practitioners do. However, the person at the center of all of this, the person receiving the care, the person who is paying for the care along with their insurance company usually, is/are the patient and their family. Their perspective is often very different, and their wishes are very often not aligned with health care practitioners views of what is sensible, practical, economical, etc. They are invested differently. This is their body/mind and their life, and from the point of view of their family members, this is their loved one. Their priorities are theirs and shouldn't be chipped/bludgeoned away at by health care practitioners who are aiming to do some social good/conserve resources etc.

Patients have the right to be told by their physician what their medical problem/s are; what their treatment options are; the risks and benefits for each treatment option and the likely outcomes of the various treatment options, including the likely outcome if the patient chooses to receive no treatment. Then it is up to the patient and their family to decide what they want.

I think health care practitioners tend to forget that the patient/their family often only wants to be provided with sufficient information for them to make an informed decision, not to have health care practitioners make their decision for them. They have the right to make their own decisions about their health care, and whether or not we believe they are making good decisions is irrelevant as our beliefs are based on our perspectives/values, not theirs.

I really think our angst is misplaced. When we (health care practitioners) gnash our teeth about patients end of life choices/other health care choices, I believe we would be better off doing some introspection. Our perspectives/values are ours not our patients or their families.

WoundcarePhilRN · Mar 1, 2017

The ACA is a rip off. Our plan was fine before the IRS got involved. Who can afford it? Why do you think Trump won the election and the democrats took a historical loss? You can slice it any way you want to fit your narrative. The democrats passed a bill without reading it. Like Pelosi said "We have to pass it to see what's in it away from the fog." I'm delighted Trump is in office and want to see it repealed.

Skippingtowork · Mar 1, 2017

$450 a month for a family premium is the employee's contribution, not the entire amount. Even pre-ACA, the average total premium for a family plan was just under $15,000.

You're correct, but before I got coverage, my husband was covering himself and 3 children for about the same amount and he is self-employed, so that was the entire amount. He then for a short while covered himself only for $250. Prior to ACA they were covered under another plan which was employer sponsored and left me with thousands of dollars in debt. Took me years to pay it off. Thank goodness for payment plans.

But back to the OP comment, her husband's plan is employer sponsored also.