Opinion

The public option in the real world

Like many other doctors, I’ve been looking at my panel of patients and trying to decide whether a “public option” in health reforms will help them. Unfortunately, I can’t think of a single patient where it will.

As an internist, I have a varied practice, with patients ranging from rich to poor, from chronically ill to “worried well.” On any given day, I see at least one quarter of cases (including Medicaid patients) without charge; one or two come in without insurance and pay me cash. Most of the time, I accept the patient’s HMO or Medicare without looking closely at how much I get paid.

The biggest problem I’m having now is the shrinking network of doctors to refer my patients to for procedures or specialty evaluations. The public option won’t help here — and could make things worse.

All the health-reform bills include hundreds of billions of dollars in cuts to Medicare and/or Medicaid payments to hospitals and physicians; inevitably, more and more of my colleagues will decline to play ball with public insurance. And if there is a public option, the private HMOs will have to cut their reimbursements to us in order to compete — so that more doctors will drop out of private insurance, too.

My patient Jeff (not his real name) works part-time as a janitor and doesn’t quite qualify for Medicaid. He has catastrophic-type insurance with a high deductible that doesn’t cost him very much but covers serious illness. I see him for his high blood pressure and charge him a minimal amount.

A bit of a hypochondriac, Jeff calls me often for reassurance, which I happily give. He’d likely qualify for a public option — and be liberated to go to the emergency room for a minor complaint whenever I was unavailable, which he’s reluctant to do right now. (After Massachusetts adopted universal insurance, similar unnecessary visits to the ER rose.)

My patient Celine is a 50-year-old administrative assistant at a small advertising firm. She can barely afford her share (about half) of the premiums for her basic, no-frills HMO coverage. With a troubling family history of breast cancer, she’s comforted by the idea that a public option would provide better, cheaper insurance than she has now. But I worry that her employer might be more inclined to “dump” insurance — and that the public-option insurance will prove unacceptable to the doctors she’s used to seeing, just as Medicaid is.

After all, Celine’s HMO is still useful — I can find her a gynecologist I trust to give her routine exams, an excellent gastroenterologist to perform her screening colonoscopy and a radiologist to do her yearly mammogram. “Be careful what you wish for,” I tell her.

I have discussions with my patients every day about the health reforms before Congress.

A patient who’s moving to Nevada doesn’t understand why she can’t keep the low-cost insurance she has. If insurance were portable, she says, there could be more competition. The public option might provide portability, I tell her — if you qualify, and it’s available in both the states you’re moving between. More important, it’s unlikely to provide coverage much better than Medicaid. There are better ways to get portability — starting with reforms to let people buy insurance across state lines, the way large companies do now for their employees.

Another patient, reaching 65 and considering retirement from his accounting firm, fears that Medicare will soon lose its purchasing power, that resources will be shifted away from it to pay for the public option. “Bad time to be 65,” he says.

The problem is worse than he thinks: I have to admit to him that, if I can no longer order the tests and treatments I think will help him, I might have to drop out of Medicare myself.

“I’ll continue to see you for a minimal charge,” I tell him. But he isn’t comforted by that — focusing instead on the promise he thinks the government made to him 40 years before.

Marc K. Siegel is a practicing internist and a Fox News medical contributor.