On healthcare, not what the doctor ordered

Mitt Romney marked the second anniversary of the Patient Protection and Affordable Care Act by calling for its repeal. Referring to the act as “an unfolding disaster,� he advocated free-market initiatives to improve access to care. Yet Romney never explained how the free market could help uninsured individuals like my longtime patient Joyce.

Joyce, a diabetic in her 60s, works for a Los Angeles church and spends much of her time doing charitable work in Africa. The church does not offer health insurance. As a diabetic with high cholesterol, Joyce has been virtually uninsurable for most of the time I’ve treated her. With her preexisting conditions, no insurer would take her even if she could afford the premium. Insurers know that diabetics like Joyce are much more likely to become ill and generate expensive bills, and the free market incentivizes them to identify high-risk individuals and exclude them.

Free-market advocates seldom focus on the plight of those priced out of the insurance market. These patients tend not to get care when they need it, and when they do, their physicians face inevitable conflicts between providing high-quality care and keeping costs down.

This week, for example, I received a reminder from my medical group’s pharmacist that Joyce’s cholesterol is too high despite the medication she takes to control it. The pharmacist recommended switching her to a more potent drug. But when I checked online, the cheapest local pharmacy I could find was charging $120 for a month’s worth of the recommended drug, versus $6 for her current one. I told the pharmacist that I would refill her current medicine and that we should recheck in three months to see if the price for the other had dropped. Should doctors really have to follow drug prices like market analysts in order to care for their patients? Welcome to the free market in healthcare.

Despite her tight finances, Joyce makes an effort to get the preventive care I recommend, including mammograms, pap smears and blood tests for her diabetes. Sometimes, though, cost considerations interfere. As a diabetic, Joyce faces risk of retinal eye injury that can cause blindness. Although such injury is preventable with routine eye care, Joyce has not visited an eye doctor for more than two years. A colonoscopy to prevent colon cancer is now recommended at age 50. Joyce is more than 10 years overdue for hers. Why? It would cost well over $1,000.

Joyce’s experiences outside my office have been even worse. When I called to discuss her cholesterol medication, she mentioned to me that she recently suffered a bout of chest pain and visited a small community hospital near her home. The doctors told her she needed overnight observation. She went home the next day with a hospital bill of more than $19,000, plus hundreds more in physicians’ charges. Were the services Joyce received necessary? She’s not sure.

Fortunately for Joyce, her healthcare nightmare is ending. She has just turned 65 and will now be eligible for Medicare. Soon she will be able to get the basic tests and medications that she needs after years of devoting herself to the impoverished in Africa. But I can’t help but wonder why so many of those younger than 65, living in one of the world’s richest nations, must avoid care or risk financial ruin.

Despite Romney’s optimism, free markets will never solve the problems Joyce faced. Health insurance for someone like Joyce, if obtainable, would cost thousands of dollars a year, and no free-market approach to healthcare will make that affordable to her. If universal coverage is the goal, there is no alternative to subsidies funded by employers and taxpayers. These subsidies — along with an individual mandate designed to bring younger, healthier people into the pool — form the basis for President Obama’s healthcare plan. Those who call for “repealing and replacing� it should explain who would be covered by the “replacement� and how the care would be funded.

The national debate on healthcare will take center stage this fall as Obama squares off against his Republican opponent. The country deserves a frank discussion of the major policy questions raised by the plight of the country’s many Joyces. We have to ask ourselves the tough questions: Should healthcare coverage for the uninsured be broadly subsidized? Are we comfortable with millions of Americans continuing to live in terror that something serious will go wrong with their health?

This is a conversation we need to have as a nation, without the partisan political posturing and gamesmanship that so often cloud the issues.

Daniel J. Stone practices internal medicine and geriatrics in Beverly Hills.