i encounter the soul-crushing Soviet-style health care our nation will soon be plagued with… and there’s something awfully familiar about it

My wife and I decided to get vaccinated against the flu. Despite a great deal of media and internet hysteria, this is not only not mandatory but actually somewhat difficult to achieve, at least in central New York. Flu vaccine wasn’t available at any of the doctors’ offices we called, and the county, which had been offering vaccine clinics, wouldn’t let you sign up anymore. So we turned, once again, to the always-ready teat of Mother Army. We drove the ninety minutes up to Fort Drum, home of the 10th Muh-fucking Mountain Division:

10th_mountain

You know... because the swords make an X.

People at Fort Drum are very gung ho and kickass, and I even got some static from the civilian at the front desk of the Soldier Readiness Center for, as far as I could tell, having a beard. “What’s going on here?” he asked, gesturing in a circle around his face.

Anyway, we eventually ended up going to the “MTF,” or military treatment facility, to get our shots. Under Tricare Reserve Select, which is our glorious partly-socialized health care plan, you can get care in one of three ways: go to an in-network provider and pay 15%; go to an out-of-network provider who agrees to Tricare’s rates (plus an overage) and pay 20%; or go to an MTF. If you choose to go to an MTF, the treatment is, apparently, free. But it’s on a space-available basis, and Reservists are the lowest-priority group.

BUT. It’s free, and they have vaccines.

I was frankly expecting at every turn that there would be some bureaucratic snag — that someone would decide we weren’t allowed to be there, or that I wasn’t high-priority enough to deserve a vaccine even though my unit required me to get one. But actually the nice young man at the service desk told me he was in the National Guard himself, and if I would just go to the Medical Records desk and ask to be put in the system, he would see what he could do for us.

Ah-ha, I thought, here it comes. The inevitable Kafka-esque nightmare. This is the Army — undoubtedly there’ll be some 27b/6’s to fill out.

Sadly, though, my fears of an impassive and all-powerful gatekeeper at medical records never materialized. Instead a very polite young woman put me in the system in about 2 minutes and handed me my ID back. Then we went back to the service desk, where the National Guard guy put in a request for us to get vaccinated.

I shit you not — twenty seconds later a nurse burst out of the door and called out Elana’s name. We were amazed — amazed, dammit!

So we got our shots, and now we won’t get the flu. (At least, not the regular flu — H1N1 vaccine is still so hard to get around here that even the Army doesn’t have it.) But this sort of got me thinking about where I had seen prompt, efficient, friendly care like this before.

Surprisingly, it was NOT in the Army. Active duty service members have kind of a weird deal with the military — your dependents are covered by Tricare and get to go to the doctor at the MTF or off-post or wherever, but you go to the medics. They determine, by some arcane methodology that is the secret wisdom of their tribe, whether you are malingering or really in need. If you’re actually sick or injured, you get to see a physician’s assistant who is empowered to prescribe ibuprofen and to tell you to lay off it for a few days. If you’re a healthy guy like me, that’s as far as it usually goes. (If you’re really hurt, of course, they send you to the hospital — my buddy Travis broke his leg during combat PT and received excellent care at the Fort Lewis MTF.) It’s not a bad system — I’m sure it keeps costs down — but it’s a little unpleasant for the end user, because your initial conversation is always with someone who assumes you’re just trying to get out of doing PT.

No, what the MTF reminded me of, more than anything, was the year that I had Kaiser Permanente insurance. Kaiser is the country’s largest non-profit, and it’s had mixed reviews recently (most notably from Michael Moore, who in his movie Sicko accused Kaiser of dumping homeless patients on the street). But when I used them, I quite liked them, partly because they tended to emphasize good preventive care (when I went to Brazil, all my travel inoculations were free), but mostly because their system of organization was extremely clear and transparent.

Kaiser hires (or contracts) its own staff, it has its own clinics, and everything is self-contained; Kaiser is a kind of socialist state in miniature. There’s never any question of whether your insurance is accepted at this doctor or that, there’s no billing department, and there’s no anxiety that something you thought was covered will turn out not to be. If they’re going to refuse you care, they’ll do it directly, to your face, and not through letters and automated messages. But mostly you just show up, and they treat you. I found it a very satisfying experience for $89 a month.

Let me now anticipate criticism: the downside of such a system (or a single-payer system, which would be the same thing writ large) is that you don’t get to “choose your doctor.” You see, basically, whoever’s on duty at the Kaiser clinic you go to.

To which I say… “So what?”

Listen, I’ve had no insurance, state-sponsored insurance, employer-sponsored insurance, and private insurance. I’ve never had a personal physician. I’m an American under 40 — I don’t go to the doctor unless there’s something wrong with me, and there’s never been anything wrong with me. This pregnancy is the first time I’ve had to shop around for a medical provider in my life, and for all that I’m making an informed decision about it, I might as well be throwing darts at the list of Tricare-approved physicians.

Back when we though we thought that we might be paying out of pocket for a home birth, we interviewed midwives at three different practices before settling on one. Partly this was because home birth midwifery is a cash business, so unlike in most medical situations you can actually find out in advance what the price is. Mostly it was because a midwife is as much an advisor and companion as a medical practitioner, and so we wanted to find someone whose personality meshed with ours. And midwives themselves encourage you to do that. They’re unusually concerned with getting along and developing a rapport, even a friendship, that will carry them and you through the birth process.

But Syracuse essentially doesn’t have home birth midwives, and also we began to get a little bit nervous about our ability to pay cash. So we’ve been going through the process of attempting to “pick,” from an insurer’s list and a few hopelessly inadequate online reviews, our OB/GYN. It’s a stupid, pointless process. In the less than three months between our arrival in central New York and the birth, there’s no way we’re going to develop a relationship with “our doctor,” but even if we had been going to this practice from the beginning, look at the math. There are five doctors. You go to the OB for a number of visits during pregnancy — at first every month, then every couple of weeks, and in the last two months every week — but of course the vast majority of the work in each visit is performed by nurses and nebulously-defined “medical asisstants.” You see the doctor for seven to ten minutes. So you’ll meet each doctor, probably, but the actual amount of total face time you get with each one boils down to something less than forty-five minutes.

And then when you get to the hospital, of course, you have no way of knowing which of the five doctors in the practice will be covering your birth, but if you’re having a fairly straightforward birth it hardly matters, since, again, the nurses will do all the work and the doctor will come in right at the end to, uh, “catch”:

Ready.

All of which is fine, and that’s the way the system works, and incidentally, God bless nurses, who are the backbone of the medical system and without whom we’d all be fucked. But if that’s the way it is anyway, then why does everybody get all exercised about choosing their doctor? I don’t have nearly the information I’d need to determine if one doctor is vastly more (or less) qualified than another, so that leaves, basically, personality and philosophy. But 9 times out of 10 I’m pretty sure people are picking their doctors based on insurance anyway, so why bother with the pretense that I could find a doctor whose personal predilections, peeves, and peculiarities match up with exactly with mine? In this area, there’s exactly one practice that takes our insurance and does births at the hospital we want to go to. Sort of takes some of the surprise out of Christmas.

(And that doesn’t even take into account the fact that if I’m fussy about who I see, it’s naturally going to take longer for me to be served. Put it this way — do you want to be seen today by a doctor, or in two weeks by your doctor?)

All of which only pushes me further toward a socialized system as potentially the cleanest, easiest, most straightforward system of health care. Stop diddling me around with promises of “choosing my doctor”; I don’t choose my doctor now. And if that’s the way it’s going to be, I’d rather not go through additional irritants of dealing with billing and nobody quite knowing what anything is going to cost until they negotiate it with your insurer. Just get everybody under one roof and assign me to whatever doc is available next. If it’s as painless, efficient, and practical as either Kaiser or the MTF, I’m pretty sure I’ll be okay with it.

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2 responses to “i encounter the soul-crushing Soviet-style health care our nation will soon be plagued with… and there’s something awfully familiar about it

  1. I wonder if choosing your doctor means choosing a practice, since no docs work alone anymore. I see a PA at the Women’s Place, which fortunately for me has a gyn I like too. Papa’s primary is also there, an ex-wine maker from CA, kind of alternative, new age dude who oddly clicks with Papa.
    I tried a couple other places before settling here.
    And I manage to see the same person. What folk mean by choosing the doc I think has a lot to do with that,which doesn’t happen at Kaiser. But Kaiser like my practice would have all your records in one place and that is really essential, especially for the family practice. We also got to choose the derm person and the surgeon who did my hip.
    BUT
    I have state health insurance, a very good policy.
    And we have always been blessed with that kind of good care.
    In essence, I completely agree with you about socialized medicine. But then I am headed toward Medicare, the ur-teat of medicine.

  2. You don’t want to be the guy who knows his doctor. I have patients who know me very well and we communicate by email several times a week and are in each other’s cell phones. But they would rather not be in a position that requires them to know me that well.

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