It was October 2008, I was doing my primary care rotation at a suburban clinic in Xoxocotlan (endearingly called Xoxo, "ho-ho") a small town outside of Oaxaca, the capital city of the Mexican state by the same name. It's a public medical clinic, called a centro de salud, and I spent 2 weeks here, most of which were spent in the consultation room with the uncomfortably touchy, sexual-harassment-lawsuit-waiting-to-happen doctor, but I also shadowed at the vaccination clinic, the nutritionist and the nurses station. It's your average primary care clinic, fairly well equipped, well staffed and on par with the average primary care clinics I know of the in the US. This clinic is nothing special or out of the ordinary in any sense, but it was here were I discovered an important concept of health values.
Read my Xoxo blog post (and other Oaxaca posts)
http://samantha-in-oaxaca.blogspot.com/2008/10/honeymoons-over-back-to-reality.html
It must have been a nurse who uttered those words that shook my soul to the core, because we all know doctors are too self-consumed to share such wisdom. We were checking a patient in when she asked the elderly patient to pay for her visit. Unfamiliar with the insurance system in this country, I asked her why she should pay for her visit since Medicaid in the US would cover the visit for patients like her. She responded that everyone should pay for their medical visits because we can not value something unless we are willing to sacrifice something else in exchange.
Whoa. Lady, you just blew my mind.
How do we as individuals develop our sense of value? There are lots of things that play into our sense of value, but our families and our upbringing play a major role. It was your parents (or whomever raised you) who taught you how to shop for groceries, how to budget for the family and how to use credit. Our sense of value in monetary, time management and relational ways are the most commonly used one, but just how do we learn to place value on our health? Obviously this issue is more complicated than the value of $0.89/lb for red potatoes vs $0.92/lb on Russett potatoes. We can't just shop around in the sales rack of our health insurance. How can we put a budget on our health care expenses? The American health care system isn't designed that way, we cannot independently determine value, our insurance plan dictates how we value our health. A person with a comprehensive insurance plan and a low co-pay will have strinkingly different opinions on health value than a person without health insurance.
Our health system is commercialized and skewed to benefit the bottom line of insurance companies and not the individuals. It's an industry that permeates every aspect of our lives because without health, we have no quality of life and we are willing to pay what it takes to keep us going. Everbody gets sick, everybody get injured, everybody needs access to health care and insurance is how Americans get access.
For those who don't know, this is how insurance works: Everybody pays into a pool and in turn they get certain services. When an individual needs services, the insurance company takes money from the pool to cover the costs. In order for this to work, very few people should need to use services because the amount of money sitting in the pool must exceed the amount of money spent on services. That's why people with preexisting conditions can be denied from insurance: they will definitely need to use services and take money out of the pool and be a financial burden on the insurance companies. Many, but not all, private health insurance companies are for profit and will do what it takes to keep their money pool nice and big. So co-pays and premiums go up, eligible services get cut and the amount spent on services rendered gets topped off, after which you may be required to pay out-of-pocket. Yeah, they are the bad guys, but hey, that's capitalism in health care for ya.
While I strongly support a public option in health insurance, I don't think of private insurance as the devil: A healthy competitive economic environment renders high quality services at the best prices. While some employers provide options for health insurance plans to choose from, competition in the classic sense within the health care market does not exist: There is no transparency in prices for services, a concept we really would not accept in any other market. We pay a fixed price for services regardless of how much that service costs at that hospital or clinic. The medical facility bills the insurance company whatever their rate is for that service and as prices go up, premiums and co-pays go up for the individual because the insurance company doesn't want to eat those costs.
Imagine walking into a car dealership, buying a car and not knowing what it costs until you get your Visa bill. That's what the medical facilities do to insurance companies, who in turn charge us more. Costs for the same service varies from clinic to clinic, sometimes very drastically, but the consumer is unaware because we don't know what the prices are to compare in the first place. Using the car analogy, imagine the exact same car from two different dealers, one is $1000 more but you won't know that and therefore cannot get the better deal. What if our other perceptions of value were skewed like our health values are? Imagine having to pay an excessive amount for getting a haircut by a certain stylist at a certain salon if it's not within your PPO. Paying full price for Tropicana orange juice because only the store-brands are covered by your prescription plan. Only being allowed a 15-minute appointment to see your tax preparer. It sounds so ridiculous in other circumstances but somehow we accept these terms when it comes to healthcare.
Imagine walking into the front desk of a clinic. As you wait in line to check in, you look overhead above the counter and see a menu:
#1- 15 minute visit with MD- $20.
#2- 30 minute visit with MD- $35.
#3- Annual exam- $35, includes basic blood panel.
"Yeah, hi, let me get the #3, supersize it. Ooo, the colonoscopy is 2 for $20? I'll take one of those too."
Hey, you just never know.
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