As one glances through the huge media coverage of health reforms in the US, one is amazed at the way the heath care issues are debated. The debate is more focused on insurance, drugs, medicare and medicaid complexities, billing by hospitals, use and misuse of medical technologies in scanning the patient ailments and so on. There is very little discussion on the “patient” and the “doctor”, their relationship and how they care with concern and compassion. Many public health experts and primary health care researchers are concerned more with the primary care of the vulnerable groups of people in the US than with the hospital care. As per Kaiser Family Foundation, US is spending as much as $2.6 trillion annually on health care. US health indicators are among the worst among the high income countries .Since 1960, the US dropped from 12th to 46th in infant mortality rankings (below Cuba and Slovenia) and from 16th to 36th in Life expectancy (below Cyprus and Chile).

In certain neighborhood communities, like Baltimore, Chicago and Los Angeles, the life expectancy for subsets of the population is lower than that in Bangladesh. Writing in the Stanford Social Innovation Review (Volume 10, Summer 2012) Rebecca Onie, Paul Farmer and Heidi Behforouz – the  health experts from the Harvard Medical School – said that the misalignment between the expansive goal of “health” and cramped definition of “care” has cost the US untold lives and treasure. Yet realignment is in reach, through expanding the scope of the health care, the place where it is delivered and the workforce that provides it, the US health care system could significantly improve health outcomes and reduce the inefficiencies”. In the 60s, half of the doctors in the US worked in primary care but today barely 30% do. Expanded insurance coverage will increase the number of patients seeking care but from the same number of physicians. With 21 million potential medicaid patients expected to enter the health care system in 2014, primary care physicians will face double burden because of too many needing care, particularly the elderly and the poor.

Good health at low cost was and should be the dream of poor and rich countries alike. But unfortunately the crony capitalism is showing its ugly face even in the field of health care in the US having done enough damage in the field of banking and finance. In order to get good health, four Ps are important – the patient, place, provider and product (service, drugs, and outcomes). Except the first P, all the remaining three Ps are in the limelight now. Recently, New York Times (July 12, 2012) reported about the price charged for drugs by the doctors. When the pharmacy sells a heartburn drug called Zantac, each pill will cost about 35 cents, but if the doctor dispenses it to a patient in person in their office or consulting room, they charge ten times the original price i.e. $3.25 a pill!! Instead of sending patients to drug store to get drugs as per the prescription, the doctors dispense drugs in their office or clinic, with the bills going to insurers, the doctors can make tens of thousands of dollars operating their own in-office pharmacies. In some hospitals, patients are flooded with several bills to pay. According to some medical bills advocates, some patients are billed as much as $11,000 for even minute hand surgery. There seems to be a tacit understanding between insurance companies and the hospitals to inflate the cost and bill of the patients! The insurers negotiate a different rate and if you are uninsured or under-insured or out of network, you are asked to pay full fare. The uninsured have no bargaining power, which is why they are expected to pay much more. What will happen to the poor families who cannot have two full meals and forget about health insurance?  Where is the health care for them?

Doctors in big cities like New York are overloaded and they have no time to talk to the patients to know their social needs like nutrition, early childhood care etc, which are part of primary health care. According to Health Leads Survey in the US, in some crowded hospitals in New York city, doctors spend hardly an average of 2 minutes of an average of 15-minute patient discussion. Medical care devices is another area with good business prospects  and in the name of mobile health, devices like blood pressure cuffs and glucose monitors  enable physicians and other care providers to check and treat patients conditions without being physically present. By keeping patients out of the hospitals, these medical devices may reduce cost and improve health. But the big question is if they fail to work, who will bear the cost of patient’s life and death situation?  The providers are also afraid of the repercussions that new medical technologies may cause to them and lead to many claims and damages. To conclude with a capitalist slogan which says “customer is king”, why not in the context of health care reforms in the US, the slogan is changed to “patient is king”…. Long live the patient!

(Kulkarni is professor emeritus, SIT, Tumkur, Karnataka. He can be contacted at manu.n.kulkarni@gmail.com)