I am now a semi retired older physician who started practicing rheumatology in Syracuse in 1975. During the recent government impasse, I experienced a curious relief that universal health insurance might not happen. Although I have supported universal health insurance for decades, working within Medicare guidelines as made me suspicious of government control. I doubt most patients care about documentation requirements in order to bill for medical services through Medicare. Patients might be surprised to learn a complete review of systems encompassing 12 areas of possible complaints must be documented in order to bill for a complicated consultation. In the past, we [the physicians] could simply ask whether anything else was bothering you. Now we must go through a laborious inventory asking about menstrual problems, memory loss, extra-marital sex, etc., and whether or not you are using a seat belt and are agreeable to routine HIV testing. I have always resisted becoming the patient’s biographer as most of the data is none of my business, and the answers do not usually impact my specialty services. Medicare forces me to go way beyond my comfortable limits. The process started as an innocent attempt to ensure appropriate services were rendered, but has evolved in typical government fashion, to include a 1-2 page confusing list of mostly irrelevant issues.

I remember when everyone paid directly for services. Then, it was not unusual for some patients to decline expensive investigation. Many would refuse additional x-rays especially if there was no direct impact on treatment. With insurance, patients have already paid. They want their money’s worth, which means some want every test and treatment possibly relevant. Many expect an MRI of the affected area and feel neglected if not done.

When patients paid directly they limited their requests to attainable goals requiring expert opinion/services. Now, in a further attempt to get their money’s worth some keep adding on additional complaints many of which are impossible to solve satisfactorily. For example, being overweight and fatigued usually has a straightforward solution… eat less and exercise more. With insurance, some feel entitled to diet advice, appetite suppressants, in depth evaluation to exclude anemia, cancer, etc.. Modern medicine has not solved the problem of how to reduce fatigue and excess weight with a simple pill. Good health is not yet effortless, but insurance makes it worth a try.

Another consequence of insurance results from the natural tendency to discount advice that comes for free. Our recommendations, which used to cost real out of pocket money, is now treated as coming for free in the same way as supplement advertisements, or cheap shot advice off the Internet. Most pay directly for their lawyer’s advice and are often happy to do so. I doubt this would be the case if/when legal advice becomes a government supplied insurance benefit with little or no direct payment required.

My last reservation is that perhaps lifesaving healthcare is not affordable. We can often afford to patch things up for hours to days, but often treatments such as intensive care unit support for months, organ transplantation, or intensive genetic testing are very, very expensive. We have been willing to spend enough so that the sick and dying do not get left in the street, but are we able to pay indefinitely for costly care that could consume over 20-30% of GDP?

Nevertheless, the nagging discontent with the hidden consequences of insurance pale by comparison with the frustration that develops when simple effective treatment cannot be delivered due to lack of funds. I therefore still support the affordable care act but worry about some of the consequences.

Hopefully, these issues can be addressed to evolve a smooth running efficient medical system. But given our current collective inability to work together, I am not holding my breath.