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Making sense of the healthcare debate

Posted Oct 30 2013 5:33pm

by Kent Bottles

"Men govern nothing with more difficulty than their tongues, and can moderate their desires more than their words." - Baruch Spinoza.

The most depressing aspect of the debate about the transformation of the American healthcare system is how liberals and conservatives talk past each other. It is hard not to get frustrated when zealots on both sides of the aisle refuse to listen to each other and refuse to learn from each other.

The "ObamaCare 2016: Happy Yet?" op-ed in the Wall Street Journal last week serves as a prime example of an unbalanced and unfair attack on the Affordable Care Act. Bradley Allen, a pediatric heart surgeon, blames the ACA for the following:

  • Physicians discouraging their children from going to medical school
  • The rise of expensive concierge medicine
  • The decline of private practice
  • The increase of physicians working for integrated delivery systems
  • The shortage of physicians

The fact that all of these problems were plaguing the healthcare system long before the ACA was passed is completely ignored by the author.

Many of my conservative friends told me the ACA is making medical school unattractive for smart young people and that less qualified students will apply for admission. So far, the facts do not support this conclusion. The average acceptance rate at U.S. medical programs for fall 2012 was only 8.3 percent, according to data reported by 114 ranked medical schools in an annual U.S. News survey. Medical school applications are at an all-time high.

Supporters of healthcare reform can be as dogmatic and unfair as conservative commentators like Dr. Allen. Viewers of Dr. Oz and readers of the New York Timesare likely to conclude half of all cardiac stents placed for chronic heart disease are unnecessary. The reality is somewhat more complicated.

I am happy to report that there are two excellent examples of balanced and fair discussions of some of the tough issues facing all of us in the health care industry. The first is a New Yorker article by cardiologist Lisa Rosenbaum who acknowledges stents can be overused:

"Of course we should not tolerate inappropriate use--subjecting patients to harm for the sake of a profit is unconscionable. Moreover, given that seventy-five75 to eighty percent of patients with chronic disease believe that stents will prevent future heart attacks and prolong their lives, it is our responsibility as physicians to do a better job of explaining when this is not the case."

However she also discusses how difficult it is to provide evidence-based care:

"If it's hard to apply the findings from any one trial to the treatment of a particular patient, it's harder still to use data from many trials to create guidelines that can be applied to any patient. When a group of expert cardiologists were asked to do just that, they recognized that there are many factors to be considered in addition to medication—including the acuity of the disease, the patient's degree of chest pain, the results of stress tests, and which of four main arteries are blocked. When you account for all of these factors, you come up with over four thousand clinical scenarios for which stenting may or may not be appropriate, many of which can’t be mapped precisely to a clinical trial."

Her discussion of the complexity of treatment decisions for patients with chronic heart disease has much to teach both the skeptic and the advocate of the ACA.

The other example of respectful debate where both participants can learn from each other occurred in surprising place: The Daily Show. The YouTube ACA debate between the conservative Charles Krauthammer and the liberal Jon Stewart makes me hopeful that rational discourse is still possible in 2013 when America seems to be divided between those who believe healthcare is a right and those who believe it must be earned.

Kent Bottles, M.D, is a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics.

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