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Compassion vs. Prudence: A False Dichotomy

By Dr. Ina Roy-Faderman

On Saturday March 3, California’s State budget conference committee approved a 2011-12 spending plan that includes almost 1.5 billion dollars of cuts in Medi-Cal (California’s Medicaid) funding as well as other significant health care cuts.   State leaders are negotiating right now to finalize the cuts, but pundits and politicians all over the U.S. are already extolling California as an object lesson in the virtues of prioritizing financial prudence over compassion.

I could easily spend this whole blog post making a case for putting compassion over economics. My fellow physicians, my students and I know that these cuts will hurt people.  In fact, over 200 physicians and medical students across the state told Doctors for America and California’s state leaders about the devastating effect that the proposed cuts will have on their patients. But beyond the human toll, it does not make economic sense to deny people care.   Providing services to those Dr. Marsha Epstein, a practitioner in Los Angeles, calls “our sickest and most vulnerable patients – children and the poor” isn’t just the compassionate thing to do; it’s also the only practical thing to do. Not just for our well-being for those misty “future generations” but also so we don’t disrupt our immediate economic recovery.

The cuts to health care being contemplated by the state of California include caps on the number of doctor visits per year, medications covered, and drug costs covered, as well as reduction to basic health care coverage for approximately 700,000 children. The reduction of reimbursement to physicians alone “would,” as Dr. Margaret Stafford, San Francisco, sees it, “severely hamper our ability to provide even the most basic standard of care.” Dr. Matt Hickey, San Francisco, notes that Medi-Cal payments covered only rent and office staff in his private practice; if coverage is cut, “docs will actually lose money on Medi-Cal patients.” With increased copays for medication and other treatments, Dr. Clifford Wang of San Jose notes that “worse exacerbations of mental illness and substance abuse” will follow and homelessness will increase.”  Dr. Hickey even foresees significant loss of life: “People will die of preventable illnesses and end up hospitalized for illnesses that are easily treatable outpatient.”

But reducing health care access doesn’t make patients and their ailments disappear. The pain and suffering caused by the illnesses of our coworkers and neighbors will continue; the children who cannot get basic care will still be our children’s classmates. And the financial cost of caring for those patients will return to us through the need for increased services from County hospitals, social services, and emergency rooms.  And who pays for those services, in money, time, and economic disruption? Taxpayers: that’s you and me.

To add injury to illness, by the time patients are forced to seek care at an ER or County facility, their conditions are much more costly to treat.  Dr. Martina Nicholson of Santa Cruz describes this downward spiral: “I have patients who are on more than 6 medications for multiple chronic conditions. If [they] are limited to 6 medications, they will end up in the ER and require even more money to care for them.” As someone who works in the arena of infectious disease and public policy, I see what happens when patients with significant or life-threatening infectious illness like tuberculosis delay therapy; not only is treatment more difficult and expensive but the expense is multiplied by the number of persons to whom the infection has been transmitted.

Concerns about the fiscal impact of cutting health care isn’t self-interested or speculative griping on the part of a few physicians; health care costs really do increase when you cut care. To take a single example, poorly- and un-treated diabetes cost the US taxpayer 25 billion additional dollars; these costs could have been averted with appropriate primary care for individuals with diabetic complications. Most of the savings from early intervention would come from public insurance programs such as MediCare and Medicaid. ( And this calculus does not include hospital expenditures; it does not include the loss of productive work time and work life of many patients; it does not include the subsequent economic impact on California, a state that needs a functioning work force as the foundation for economic recovery.

Dr. Cheryl Ho, San Jose, has already seen what happens when health care access is reduced because of a recession: “Every day in our county ERs, we see more patients who are forced to forgo regular doctor visits and then end up in the emergency room with drastically worsened disease that are preventable.”  She summarizes, “Please don’t kick the can down the road with such short-sighted cuts.” By pushing off the medical needs of Californians, we’re setting ourselves up for increased medical expenditures, an increasingly burdened emergency medical system, and reduced productivity of citizens of the state.  As citizens of this country, we can afford neither the humanitarian nor financial costs of kicking our health care needs down the road. 

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