Odysseus, the Terminator, and the Financing of Healthcare

Governor Schwarzenegger, fresh from many policy successes in 2006, announced that 2007 would be the year that we would “fix” healthcare in California. In that context, it was no surprise to see a quote from an article in the San Francisco Chronicle that began, “Trying to forge a consensus among dozens of powerful special interests, the legislature will begin work next week stitching together a plan to extend healthcare coverage to five million uninsured Californians.” What was somewhat surprising was that this quote was from an article written in 1990.

To say that the issues surrounding healthcare access and financing are challenging is obvious. But what is less clear is the context in which we as practicing physicians should frame these issues. Without any context, it all just seems overwhelming, making it impossible to develop meaningful and comprehensive solutions. As an extension of that, the context in which the organizations that represent all of us (SDCMS, CMA, and AMA) frames these issues thus becomes critical.

After wrestling nearly twenty years as both a representative of the physician community dealing with our elected representatives and the media, as well as a health policy professor trying to explain the nexus of politics and policy in our healthcare system to medical students, I offer a paradigm for your consideration.

Those of you with at least a passing familiarity with Greek mythology will recall the tale of Odysseus (a.k.a., Ulysses), whose decade-long effort to return home following the Trojan War came literally to define the word “odyssey.” Much like Odysseus, we as physicians may feel cast out of what we knew — or what we hoped — medicine would be. And like that mythic hero, we are trying to “get home” to a secure place where we can care for our patients to the best of our ability without all of the obstacles of the modern healthcare system.

Many of the challenges faced by Odysseus, such as avoiding the sweet-yet-deadly temptations of the Sirens, remain recurrent themes in current popular culture, and could even apply to any one of a number of “schemes” that physicians have bought into over the years in the hopes of an economically secure future. But a lesser known yet truly profound challenge faced by Odysseus was the one that seems most to parallel our place in our professional history, that being the challenge posed by Scylla and Charybdis.

Scylla and Charybdis were sea monsters on either side of a narrow strait that Odysseus and his ship had to pass through. Scylla was a six-headed monster that could reach out to grab and eat sailors off of passing ships. By contrast, Charybdis took form as a monstrous mouth that generated whirlpools of such magnitude that no ship could escape them. The dilemma posed was that it was impossible to steer entirely clear of Scylla without being caught and destroyed by Charybdis. Facing the choice of either losing some of his crew by passing near the visibly terrifying Scylla or losing everything to the serene yet deadly Charybdis, Odysseus boldly but necessarily steered clear of Charybdis. As a result, he lost six of his crew, but the remainder survived to continue the journey home.

What do Scylla and Charybdis mean to today’s physicians? In my view, they represent the two possible futures of our healthcare system. One possible future is built on personal responsibility and competition based on quality (albeit with a strong safety net for the 10–20 percent in society who need it). Systems based on such a philosophy have been, and will continue to be, stressful to practice within, but they are the systems that hold out the possibility of a future where physicians can retain much of their autonomy and feel valued as professionals.

The “Scyllas” within the quasi-private part of our current healthcare system are quite obvious, starting with the private health plans that were taken to federal court by CMA — with some significant success — as Tony Soprano-style racketeers. Our battles with health plans seem to go on endlessly, but, over time and with the interests of our patients in mind, organized medicine has prevailed and will continue to prevail again and again.

To battle “Scylla,” we in organized medicine at all levels have successfully promoted that health insurance plans be more aggressively regulated and that their dollars should go toward healthcare, not shareholder profits. But, just as importantly, we have promoted the notions that A) health insurance policies be individually owned, even if provided by an employer, and that B) they be designed more in the classic sense of what insurance was meant to be, which is to say that one’s health insurance policy should be there when one’s expenses are significant, as opposed to being used for every day-to-day expense. Longstanding policies of ours that encourage this include the promotion of tax-advantaged HSAs for all who wish to try them.

More recently, in September of 2004, and with the full support of SDCMS, CMA went one step further and became the first major physician organization in the nation to endorse an individual mandate for catastrophic plus indicated preventative services. With AMA following suit in June of 2006, this put all levels of organized medicine in San Diego firmly on the side of healthcare as a personal responsibility for the majority of Americans who can afford to take such responsibility.

We do not come to these conclusions lightly, but rather with great thought, along with the realization that the way to disarm the Scyllas of our private healthcare system is to align with our patients and work together for the betterment of their health — not the betterment of a corporate bottom line or the popularity rating of a politician (more on that a bit later).

All are not pleased with this direction. There are those who loathe the notions of negotiation and competition in healthcare, and there are those who have ceased feeling that their services have value. This latter group is concerned that the people who pull out their Visa card for their dentist, their veterinarian, and even their dry cleaner will not pull out their Visa for their physician. In short, there are those physicians who fear that they will be the ones who are eaten by Scylla.

In contrast to the challenging yet stressful “Scylla” path preferred by organized medicine, the “Charybdis” alternative would be some form of healthcare system based on a government-decreed entitlement to free healthcare. Such systems have already been proven here in the United States and worldwide to be little more than vehicles for political popularity on the backs of those who provide the care, and, ultimately, to the detriment of those who receive it. Yet their comparative serenity holds appeal.

Here in the United States, Medicare is one of our “Charybdis” programs. Initially a well-funded program and one that was attractive to both physicians and hospitals, Medicare is now a program that pays 20 percent of the nation’s healthcare bills, even though the Medicare population consumes 40 percent of the resources. A program largely immune to reform because of the fears of politicians, Medicare has frozen physician payment for seven years, plans to cut physician payment by 30 percent over the next seven years, and, with the arrival of the “baby boomers,” faces a funding shortfall of some tens of trillions of dollars by mid-century.

Yet Medicare is a joy compared to Medi-Cal, whose large bureaucracies and small payments have driven most of us away. Other countries are not so lucky, as all they have is something akin to a Medi-Cal system. Should our future follow the path of Charybdis, all of us in the profession will be truly threatened as resources for patients become scarce for all but the politically connected, and we would be all but helpless against the whims of the popular politicians of the day.

Enter our governor. An independent-thinking Republican who has worked with our Democratic-dominated legislature to forge compromises on complex issues such as the state’s infrastructure and the state’s budget, Mr. Schwarzenegger has set his sights on healthcare this year, and, specifically, the problem of the medically uninsured.

Most physicians stopped reading about the “Arnold plan” as soon as they saw the two percent tax on physician income, dismissing the whole thing as some kind of scary socialist fantasy. But it is actually more nuanced than one might initially think, and may, in fact, represent some of the finest thinking on healthcare ever produced by government.

First and foremost, front and center, the governor’s plan calls for an individual mandate for catastrophic health insurance that would apply to most Californians, including many of the currently uninsured. If our trauma networks and EMTALA laws mean that we all receive life-saving services when we need them, those of us who can afford to purchase a policy that covers those kinds of services should purchase one. This is consistent with the CMA policies that we have been advocating.

This puts the governor squarely in line with organized medicine’s view of healthcare. But he goes further. In recognition of the past abuses of the “Scylla” of health insurance companies, his plan A) calls for them no longer to cherry-pick who they cover, since everyone will now be covered, and B) requires that 85 percent of premium expense goes to the actual provision of healthcare services, which is, again, consistent with CMA policy.

More good things in the plan include a sincere emphasis on appropriate preventive care, private sector-driven patient safety initiatives, and worthy goals for information technology. And, finally, a significant increase in Medi-Cal reimbursement dollars would bring many physicians back into the program and improve healthcare access for the most vulnerable among us.

On the negative side, it is obviously a flawed notion that physicians and hospitals should be the primary funding source for all of the good things in the plan. But, frankly, it was not altogether unexpected, as the governor had explicitly forbidden his advisors from including any general taxation in the plan, knowing full well that one does not cover four to six million currently uninsured folks for free.

Our challenge as physicians — if we share the governor’s vision of expanded access, including enhanced Medi-Cal rates — is to suggest credible alternative mechanisms for financing his plan. We already have, and we will continue to do so.

Another problematic feature of the governor’s plan worth mentioning is the suggestion that primary clinics would function better if physician supervision requirements were relaxed. While incorrect, and, appropriately so, immediately opposed by CMA and SDCMS, it again behooves us to address this issue in context. Over just the past few years, over 100 of the nation’s 1,000 largest employers have been developing, if not already using, onsite clinics for their workers, often staffed only by nurses — a trend that is expected to increase exponentially. We need to fight to preserve physician supervision of nurses, but we also need to work harder and smarter to figure out how to deliver care in ways that are more appealing to people than what we have done in the past.

2007 again promises to be one of those years when physicians can be thankful that they have organized medicine — speaking for the entire profession — on their side. Much of what is good within the governor’s plan came from CMA and SDCMS, and that which is not so good is quite unlikely to happen … again, because of CMA and SDCMS.