Opinion Extra

Gordin: The complicated truth about health care

The health care debate has lost its way. Our media and public officials have framed it in terms of individual stories and a plot line instead of discussing the hard choices and details that make good public policy.

We have the bad guys. Insurance companies of course are the ultimate meanies. Pharmaceutical and medical device manufacturers find themselves under fire for having the audacity to profit from their work. Further down the list are physicians, who, according to the president, order exams and do "unnecessary" procedures to pad their pockets. Anyone who gets in the way with messy facts or objections is relegated to the bad-guy list, accused of spreading misinformation.

The story likewise contains victims - people who were denied or dropped from coverage and ended up with an unfortunate or tragic fate.

Wearing the white hat are those well-meaning people who say: "We are a rich country. We should be able to provide coverage for everyone."

The plot of the story has the feel of an athletic event, in which the Democrats "must win" for the sake of their president, and the Republicans need a stop.

In this story, I guess I am a bad guy, because from my small perspective of this enormous system, I see daily the problems where the proverbial tire hits the road.

Take for example imaging studies, which commonly find thyroid nodules. Some estimates say 50 percent or more of the world's population have one. The vast majority are benign, but once in a while, they are cancerous. There are few specific findings on imaging, so usually something else - another test or even a biopsy - is recommended. Most of us have no problem with that, but it is expensive. And most of these are incidental findings. And that is just the beginning.

Cysts on the kidneys are very common and usually benign. Still, they may not be, which leads to more testing and more expense. And this is before discussions about the better-known quandary with mammogram screening, in which a few calcifications or a nodule usually lead to a biopsy or follow-up study. We know that a certain number of early cancers are biologically stable, but we don't know yet which ones.

So the tendency is to be aggressive and do everything when something potentially dangerous shows up on a test. And why not? In our current legal environment, no physician is going to tell a patient that the thyroid nodule, renal cyst, early breast cancer - you name the abnormality - does not need to have some follow up.

A missed cancer could land the physician in a deposition, squirming while trying to explain how he used statistics to make a clinical decision. People stop being interested in stats when it comes to their health, and all those "unnecessary tests" that the president talked about take on a new meaning when it is our health that is at risk.

These few examples begin to explain why we have skyrocketing health costs. Now bring 20 million or so more people into the system, and keep everything else as it is. Don't even consider the monetary cost. Following up thyroid nodules alone would tie up resources and create a backlog of patients waiting for other exams. The system would collapse from a variety of practical problems.

Such issues, and so many more like them, need to be talked about. Pundits and demagogues on both sides would rather use emotional appeal to rally their minions, but such strategies should be rebuffed and denied extensive coverage.

Quoting statistics and talking about thorny issues such as who gets what (rationing) and how those decisions are to be made is boring and requires understanding of the issues. Journalists under deadline don't have time for that, and it doesn't sell many papers or advertising slots. And for members of Congress to familiarize themselves with the core of the problem (demand exceeding supply, leading to higher costs) evidently is asking a lot. After all, their pay is the same whether they have a clue about what they are voting on or not.

It is much easier to recite talking points, and to preach on about the universal saga of good versus evil. Very few health care professionals deny that changes need to be made, but if they are the wrong ones, the story will have a most unhappy ending, with everyone losing.

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