When We Talk About Health Care, We're Forgetting One Important Group: The Already Insured

The New York Times recently ran an article about the movement within primary-care medicine to develop systems that allow doctors to spend more time with their patients.

New technologies enabling doctors to electronically record, store and manage records, handle appointments, bill insurance companies, refill prescriptions and communicate directly with patients are allowing physicians to spend more time seeing fewer patients while maintaining their incomes.

One physician moved from a large clinic where she was required to see 25 patients per day to a smaller, more efficiently run practice where she saw only 12. Instead of only treating presenting symptoms, she was able to better understand her patients' entire history. Another doctor made house calls, managing most of his practice through special software on his laptop. Both providers maintained regular contact with their patients via e-mail.

There is overwhelming evidence that patients who get more time with and attention from their providers do better. Compliance and follow-up improves. Fewer medication errors are made. Hospitalization and re-admissions decrease. Benefits accrue not only to patients but to doctors, who feel more engaged, successful and fulfilled in their work. And, of course, society benefits in the form of lower medical costs. It's a win-win proposition all around.

Yet the progressive side in the political debate about health care tends to neglect this aspect of quality health care in favor of issues of access and cost. Who will be covered and who will pay for it dominates the discussion. Care for those with none, cheaper care for those with some, guarantees of care of everyone -- these are our goals.

But what about people who already have insurance, whether from their employers or because they can afford it? What's their stake in reform? What needs of theirs are addressed by the campaign for universal coverage? Are we writing them off as potential allies or relying on their altruism and basic liberal sensibilities for their support? In either case it's a mistake.

The pain and suffering fostered by the American health care system isn't limited to those who can't afford access to it. It occurs every day in the many ways people feel treated like a thing, and not a person, in their interactions with their providers. If we can find creative ways to put relationships on a par with cost and access at the heart of our campaign, we might energize people who today are on the sidelines of this struggle.

Behind debates about efficiency, technology, compliance and treatment outcomes lay the transformative power of relationships. The relationship between patient and doctor, it's quantity and quality, is powerfully implicated in medical outcomes.

For many people who do have medical coverage, getting in contact with a doctor is difficult, mediated as it is by labyrinthine office procedures, phone queues or office policies that simply prohibit it. Once an appointment is made, not always a simple matter, patients often wait for a long time.

When they eventually see their doctors, they are made to feel that their problems, questions and concerns are taking up too much of their providers' time, which is apportioned in 5- to 15-minute increments. Referrals to specialists often take weeks or months. Follow-up is usually left to the patient, who may or may not be proactive enough to do so.

The result is what psychologists call an "anxious attachment" to the doctor and to the medical system in general. Lacking a secure sense that one is correctly understood and reliably cared for, patients give up, become cynical or nervously dependent and needy and fail to internalize the treatment and care that is being offered. Treatment outcomes suffer, prevention strategies founder, hospitalizations and emergency-room visits increase, and everyone involved -- including taxpayers -- pays the price.

When a doctor has time to spend with a patient, a more trusting and caretaking relationship can develop. Patients feel understood. Doctors learn about patients' real lives and social context, which enable them to tailor their treatment to the idiosyncratic needs of the three-dimensional people under their care. It is axiomatic that when someone who is sick feels understood, he or she feels better, more engaged and more likely to take care of him or herself.

These issues are exaggerated among people who have no or limited access to care. But there isn't a person I know who has medical insurance who doesn't have a story about neglect or mistreatment at the hands of the medical system, who doesn't share the frustration of not being able to get through to the doctor or of the latter being unresponsive to his or her needs.

Recently, a family member asked me for help with her 17-year-old daughter, who had been suffering from intense back pain for two months. This girl eventually saw her primary physician at a local HMO, who told her that only the physiatrist in charge of physical medicine (including physical therapy) could order an MRI.

When she went to the PT department, she was told that she first had to have physical therapy for four to six sessions before the physiatrist would see her and, if necessary, order an MRI. My friend raised hell and got the physiatrist to order an MRI before physical therapy began, although it took 10 days to schedule. She was then told that it would be another 10 days before she could meet with the physiatrist, who would read the MRI, evaluate her daughter, and recommend treatment.

I intervened and took the daughter and her MRI to a neurosurgeon I knew at a nearby university hospital who saw immediately that there was severe disk disease and that surgery was imperative. He called the chief of neurosurgery at the HMO, who saw the patient the next day and operated on her -- successfully -- two days after that.

Obviously, without the help of someone like me who could pull strings (in another bureaucratic medical system), this girl would have suffered the fate of many other Kaiser patients who spend untold days and weeks in needless suffering because their medical system doesn't relate to them as real people in real need.

I'm sure that there are many patients at this HMO who have found their care to be adequate or even good. We all tend to accept what "is" as the way it's "supposed to be." When the rudiments of medical care are delivered adequately, and we're helped to feel better, we don't naturally judge the process critically. The problem, of course, is that we haven't experienced any alternative and when we do, the problems of the original system become immediately apparent.

Everyone has stories of going to see a specialist or an internist who spent a lot of time with them and, to a person, they leave with an enthusiastic, even ecstatic, view of how great the doctor was -- simply because of the time, interest and sense of personal commitment they experienced. Too many of the stories, unfortunately, are of the opposite.

We all have stories like this. "We" includes folks with insurance, even with decent insurance. Unfortunately, most progressive demands for universal coverage include little obvious direct benefit for us.

Yes, we occasionally hear about demands to reduce waiting times, and slogans like "quality care" might be interpreted to include concerns about time spent with providers. But, in general, all sides of this debate focus primarily on access, availability and affordability. They avoid the "soft side" of the issue primarily because of the implicit assumption that some care, even indifferent care, is better than none, and we have to start with the basics.

Thus, many of us who do have insurance support progressive health care proposals either because we fear losing ours or because we have general liberal proclivities to help those who are disadvantaged.

In my view, this is politically misguided. First, we need to speak to the widest range of needs in people we wish to organize, not just to the more "fundamental" physical and economic ones.

When a movement addresses needs for meaning, relatedness and recognition, that movement is strengthened and its members energized. For a campaign for universal coverage to succeed, it has to have the energetic support of multiple constituencies, including those that might already have decent coverage but who suffer in less-dramatic ways in the course of interacting with their doctors and hospitals. Their suffering, the suffering of bureaucratic indifference, misrecognition, anxious attachment and being shuffled around like a thing in an environment that doesn't see us as people, isn't any less politically important to address than the suffering of people without any coverage.

The suffering I'm describing might not rise to the level of tragedy, but nevertheless it corrodes our spirits, increases our cynicism and contributes to terrible and costly long-term outcomes. And most important, it's suffering that were we to address would expand our political base, reach out across class and party lines and strengthen our chance of success.

In addition, addressing the noneconomic frustrations in the current system of health-care delivery invites alliances with health care providers at all levels who are burned out and alienated in relationships with patients increasingly perceived as demanding, noncompliant and ungrateful.

People don't become doctors and nurses to provide assembly-line service or express indifference but to provide care, and systems that compress that care into 10-minute segments are as oppressive to doctors and nurses as to patients.

We on the left so often find ourselves fighting for the most stripped down and basic elements of social welfare programs. We do so because the present balance of political power makes us do so. We're realistic. We should be. The human cost of not accepting some compromise in the health care debate is too high.

But in this case, we're fortunate because shooting high is eminently practical. Focusing on the relational quality of care is not only economically practical but speaks to the psychic bruising and frustration that is so built into many encounters with the medical system that those enduring them hardly think there is any alternative way of being treated.

Such a focus, however, can bring this frustration to the surface, connecting with the experience of people who might, themselves, not be suffering from problems of availability or cost, but suffer nevertheless. It positions our movement for health care reform as one that speaks to what ails all of us.