Debate: The American Health System

As a lay person and an Indian, who has recently come up against the American Health system, I am really quite confused about who the health system actually serves. Does it serve the patients, the doctors, or in actual fact promote the interests of the health insurance companies? Is the system designed to give maximum care to the client, or to maximize the profits of the insurance companies and cut the risks of the doctors? Who decides what is good and necessary for the patient, the doctor or the insurance company? Who should decide?

As I see it, the interests of the insurance companies are paramount, the patient definitely comes in a poor second. Take a scenario where a young woman is expecting her first child. She has recently moved to a new area, and though she has plugged into a group for gynecological care, she has still not found a GP (general practitioner). In her last trimester she falls ill, consults her gynecologist on the phone, as she is reluctant to take medication without a prescription. The gynecologist says, "Ask your GP". The GP that she finds on her plan, says, "Ask your Gyne". They bounce her up and down between them, no one prepared to take a risk and meanwhile she gets sicker, and nothing has been done about it. Eventually, weekend over, she gets to see a nurse practitioner, who then prescribes the anti-biotics she needs. I had never even heard of a nurse practitioner. Where does she fit in within this whole system? Is she a nurse, or a doctor, or something in between? Is she qualified to prescribe drugs for pregnant women? You can't even get to see the GP unless the nurse practitioner decides that this is more than she can handle and then gets you an appointment to see the doctor. All very bureaucratic and time-consuming and certainly no help to the patient who wants to see the doctor now and is not totally confident about the nurse practitioner.... 

What would have happened in India? Well, you choose a doctor or gynecologist of your choice, either in private practice, or practicing in a hospital or nursing home. You make your appointment and go. Costs for consultations are not too high and any hospitalization can be covered by your health insurance, if you have one. You get to choose which hospital and which doctor, no matter where you live in the city. Maybe it's not a perfect system, but it's humane and certainly the patient has a voice in the whole process of choosing a doctor she trusts.

Let's get back to our pregnant lady. Well she's registered with a group, so she could get examined by any one of the four doctors in that practice. When it comes to the time of her delivery, she could be attended to by any one of the four doctors, though she feels more confident and comfortable with one of them. She doesn't have the choice. On her next visit, the doctor is brisk and efficient and as usual does the check up within ten minutes; has no recall what-so-ever of the last telephone conversation in which she bounced her to the GP. Is surprised that her patient has a bad cough and cold and wonders what medication she is on? She confirms the prescription of the nurse practitioner is safe for the baby and only now, four days later is the patient confident of taking the medication she has needed for many days. If you had questions to ask, fire away, while on the examination table because the gynecologist looks to be in a hurry and your time is running out. I would hazard a guess, that maybe, the insurance company has stipulated some kind of assembly line process, which optimizes the time of the gynecologist.

Come the time of the delivery, it's all very well orchestrated. You are under instruction to call your doctor only under emergency situations. Don't go to the hospital or call your doctor, even if you are a first time novice at this game and husband and wife are in a state of total panic. Sit by your clock and when for one hour you have pains every five minutes, call your doctor and head towards the hospital. Go early and you risk being turned away. Again, the insurance companies have fine-tuned this in and out of the hospital process to minimize hospital time. You've chosen your hospital, you hope like hell that your favorite gynecologist is on call, and off you go, with labour pains coming in every five minutes. Have a normal delivery and you're in the hospital for two days. If you have to have a C-Section, you stay longer, but in a smaller room. The profit motif reigns strong.

I get back to my original question, of who benefits most by the American Health System? Should it be changed? How can it become more patient friendly? I've traveled extensively all over the world and lived in England for some years. In all of these countries, I would have to say their health system serves people better. Maybe, nowhere else in the world are doctors so threatened by malpractice suites, as they are in America, and hence are heavily insured. Perhaps, it is this phenomenon which has pushed doctors into extreme caution and has allowed the insurance companies to get such a strong foothold into the system in which they now reign supreme. It can only get worse, not better unless people voice an opinion and don't let the system intimidate them as it does. You get the feeling that you are being run by a program designed by an insurance company, which has a vested interest in your health care and in consequence you do not get the personalized attention of a doctor which is what you would really like.
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- Nomita Chandy Expectant Grandmother currently in Philadelphia, USA
  1999

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