An Anesthesiologist's Take on Health-Care Reform
By RONALD DWORKIN
Every medical student learns an old adage: You can skimp on some medicine, but you can't skimp on obstetrics or anesthesiology. An elderly surgeon explained it to me this way, "In surgery, people die in days and weeks—a doctor has time to fix a mistake. But in obstetrics and anesthesiology, they die in minutes and seconds."
Twenty years ago, I became an anesthesiologist. Since then, whenever death has loomed in the operating room only to be sidestepped at the last moment, I think back on that wise surgeon. Indeed, the old adage explains why an anesthesiologist's life resembles a soldier's life. A soldier plays cards around the campfire, then goes out on routine patrol and ends up dead. The anesthesiologist jokes around with the surgeons and nurses, then, because of some unforeseen complication, his or her patient dies on the table. Although I have not personally faced such a disaster, I know anesthesiologists who have.
Incredibly, Congress's proposed health-care reform plan risks skimping on anesthesia. According to one of the health-care bills in Congress, H.R. 3200, the public option would reduce reimbursement for anesthesia by over 50%.
More broadly, the bill reflects the incorrect assumptions progressive politicians have made about the mindset of today's doctors and how the health-care system operates.
The first error involves the new taxes on high wage earners. Progressives think marginal tax rates are a disincentive to work only when they reach, say, 70%. By raising taxes to only 60%, they expect a linear increase in tax revenues. But a new culture reigns in the world of upper-middle class professionals that invalidates this rule.
If the tax increase targeted 19th century aristocrats, the increase might be linear, since Old World aristocrats worked for honor—not money. Aristocrats viewed the whole notion of working for profit with contempt.
If the Protestant work ethic described by sociologist Max Weber dominated the earth, the tax bounty would also be huge. That's because the stereotypical Calvinist businessman worked not just for profit, but because he believed it was his duty to work.
People who view their job as a calling are also eager beavers. They work independent of the tax rate because their job is a vital part of their identity.
But today's generation of upper-middle class professionals is different. They enter their respective fields to satisfy a career interest and to be of some use to society. When the novelty of their career wears off, they continue to work but do so primarily to make a good living and retire while still healthy.
Lawyers go through the change first. That's why the biggest law firms ladder their salaries in a particular way. They kick up a young lawyer's salary just when that lawyer starts to make the time-money calculation and ponder a lateral move to another industry. Each time the lawyer wises up, the firm pays him more—until he's too old to retool.
Such time-money calculations occur later in a doctor's career. But they do occur. Most doctors no longer think of their job as a calling. Few of them are Calvinists, and none of them are Old World aristocrats. Many doctors work part-time; others want flexible shifts. This would have been considered heresy even 20 years ago.
My point is that today's upper-middle class professionals are very sensitive to marginal tax rates. To preserve "lifestyle" and "quality time," they will work less. Thus to get money for health-care reform, progressives will have to tax further down the economic ladder, which means taxing the rest of the middle class.
A second thing progressives fail to grasp is the genius of the American health-care system: It unites rich and poor in a common private insurance system.
Here's how it works. When a rich person rolls into the operating room, the nurse asks him: "Would you like a warm blanket? How about a pillow?" The anesthesiologist numbs his skin before putting in the I.V. Every effort is made to make him happy.
People in the operating room pay attention to a rich patient's wishes because they know a rich person can make their lives miserable. He can complain to the hospital president, or call the mayor. But the side effect is that their high quality care becomes habitual, and all patients receive it. When a poor person complains in most environments, no one listens. But in health care, through a common private insurance system, poor people go to the same hospitals and doctors as rich people and thus enjoy the benefit of rich people's power.
The public option severs this link. Dissatisfied with government-run health care, the rich will exit the system. The poor and middle-class will be left to flounder alone inside the public system. Government-run health care will become like the public schools.
The progressives' third mistake is to skimp on anesthesiology. In no medical specialty is the spread between the Medicare rates and private insurance rates greater. Progressives expect to pay anesthesiologists Medicare rates, which are 65% less than private insurance rates, without any change in the system. But there will be changes.
Some anesthesiologists will leave the field. They are already faced with lawsuits at every turn. Something else has happened in America that threatens to tip the balance for anesthesiologists. Americans have grown very fat. This complicates anesthesia tremendously. Putting in IVs, spinals and epidurals is harder. Inserting breathing tubes is much more dangerous.
Quality of care will inevitably decline. That decline will come first in obstetrics. At the hospital where I work, two anesthesiologists work in obstetrics almost around the clock, so that a woman in labor need not wait more than five minutes for her epidural. Other hospitals are less fortunate, and have on staff at most one anesthesiologist in obstetrics. The economic crunch will eventually force these hospitals to cover obstetrics "when anesthesiology is available," meaning in between regular operating room cases.
During an obstetrical emergency, these short-staffed anesthesia departments will scramble to send someone to perform the C-section. Don't forget, a baby has only nine minutes of oxygen when the umbilical cord prolapses, so time is of the essence.
At the very least, pregnant women will be waiting a lot longer for epidurals. But more pain on the labor floor is only the beginning. If hospitals delay the administration of anesthesia because Congress skimped, needless deaths will certainly result.
Dr. Dworkin is an anesthesiologist and the author of "Artificial Happiness" (Basic Books, 2006).
so i feel like i will have done enough of this stuff.
