It’s interesting to listen to educated women talk about important issues of the day. This eavesdropping was about health reform. One would expect the discourse to be filled with insights and nuanced arguments, references to law and ethics, comparisons to other health systems and how the new reform movement will help (or hinder) members of our society. And we do. But one would also expect that there could be some form of consensus about how to proceed for the betterment of all.

One would expect that. But one would be wrong. It’s not that educated women aren’t concerned. They are. But the dividing line between their arguments cuts along rhetoric rather than reason. We are torn between our hearts and our pocketbooks.

None of us want to live in a country where everywhere we turn we are reminded of the discrepancy between have’s and have-nots. We ache at the visions of children broken by malnutrition and disease. We cry for people who, through no fault of their own, are devastated by disfigurement or congenital conditions that marginalize them from mainstream society, jobs, security and self-esteem.

Women are generally nurturers and caregivers. We can’t stand to neglect the suffering of children, the aged or people who are truly victims of circumstances beyond their control. We want there to be many options available depending on one’s ability to pay.

Women believe that health care is essential for everyone. Philosophically and morally, women don’t like the notion that affordable health care is unattainable. But agreement then diverges into whether healthcare is a right or a privilege. Should people, regardless of age, viability, potential for a positive outcome or ability to pay have the right to as much healthcare as they want, or does society have the right (and responsibility) to ration its resources according to need?

The fault lines occur when the ideal: universal entitlement, gives way to the real: implementation. It’s one thing to say everyone should have access to affordable healthcare. It’s another to insist that you and I pay for it.

But if God is in the details, let’s listen to what these women are saying.

• If everyone is entitled to health insurance (which seems to be an unchallenged premise), then does that mean those of us who do pay for health insurance have to carry those who don’t? (“I work hard to pay for my health insurance. Why should I have to pay for someone who just uses the system to sit on his ass and smoke cigarettes?”)
• What if the “conditions” are caused by lifestyle choices such as smoking, obesity, drug addiction? (“Why should we be required to pay for insurance for people who use their food stamps to buy Twinkies and beer instead of health care?”)
• If one champions free enterprise and a market-based economy, how can insurance companies be forced to cover patients considered bad risks? (“They should cover everything. They make enough money!”)
• If we live in a free country, how can citizens be forced to buy insurance coverage if they can’t afford it, or choose not to allocate money toward it? (“If they don’t have insurance, we pay for it anyway in the form of utilization of emergency rooms.”)

As responsible taxpayers, each of us makes financial decisions every day. Can we afford this? Should we pay that off? We know how much of our paycheck or bottom line goes to pay taxes, and we complain that so much is taken out of our income and that this curtails our ability to purchase things we want. That’s why it’s easy to be magnanimous in theory about universal healthcare as long as it doesn’t translate to the practical reality of increased taxation.

Listening in on the conversations people are having about health reform tells us one important thing: there is little understanding about what it is, who it will affect, and importantly, who will bear the brunt of the costs. And until we start conversing in ideas versus sound bites, we will remain ignorant of the consequences of acting on misinformation. At least women are talking with each other. It’s what smart women do.

We currently have an interesting hybrid system of care:

• Medicaid (For the poor)
• Medicare (For those over 65)
• AARP Supplement (For those over 65 who need to augment what Medicare pays)
• HMOs (Managed Care)
• PPOs (Managed Care with Choice)
• High Deductible Health Savings Accounts (Individual plans purchased for catastrophic care and where everything else is paid for out of pocket)
• Fee for Service (Cash)
• Concierge Medicine (Premium service for the wealthy)

Those who are very ill and without insurance utilize the emergency rooms of hospitals for their care, and we end up paying for it through taxes. This “uncompensated care” represents a tax burden on those who pay taxes. And a philosophical burden on those who have to make the decisions, apportion care and provide for the needs of those who show up at their doors.

Medicare recipients are entitled to health care if they can find a doctor who will accept Medicare payments (often too little and too late) because many good doctors are refusing to accept Medicare patients at all.

HMOs and PPOs are usually paid for by employers, and now more and more employers are requesting that their employees contribute. In other words, they have to have some skin in the game, and many employees (especially unions) are fighting back.

Eavesdropping on a conversation between four 40-something women, I learned that if it came to a choice between paying for Botox or a mammogram, the women said they would choose Botox. This surprised me a little, especially with all the information that surrounds us about the risks of breast cancer and the benefits of early detection. But their reasons were interesting.

First, they considered mammograms “have to,” procedures for something they wished to avoid, while they looked upon Botox as a “want to” procedure they were eager to pursue. It’s clear from their conversation that the “want-to’s” won. The immediacy of looking good now, versus the abstract of breast cancer prevention later brings home an essential challenge framing the financial discussions about paying for health care.

It appears, from this brief discussion, that the women had no difficulty talking about cosmetic procedures, sexy stiletto heels and other discretionary expenditures they would save (or go into debt) to have. But when it came to taking about co-pays or fee-for-service mammograms, the conversation took a different turn.

One of the women said she knew she was supposed to get her annual mammogram, but she just wasn’t interested. In fact, she said she “didn’t want to know.” Another remarked that she’d only have it if her doctor insisted, but since he didn’t, she wasn’t concerned. Although they knew women who had experienced breast cancer, they preferred to focus on things that gave them pleasure (despite the temporary pain of Botox injections, the discomfort of wearing their “limousine shoes” and the damage to their pocketbooks).

I wondered, how is it that otherwise educated, middle-class women opt for fashion rather than health prevention? Perhaps it’s that, at the end of the day, the pleasure principle trumps all other considerations, overriding the rational in favor of the emotional. My thought is that breast cancer, while still of great concern, is now considered a “treatable disease” and that the fear of getting it, and dying from it, is greatly diminished. The medical profession has done an excellent job of raising awareness and improving treatment, and the survivor community has been effective in proving that there is life after cancer. In other words, fear and anxiety is gone, and has been replaced with other priorities, like where to get the next Botox treatment and when is the Spring shoe sale?

Following on the heels of the Botox discussion, the issue of health care reform generated a more controversial exchange, and divided the women by those women whose insurance was provided by an employer versus those who were self-employed and paying for their own insurance. While all gave lip service to “everyone should have access to health care,” opinions greatly diverge about who should be responsible for paying for it. Those with employer-based health insurance advocate for insurance reform that covers pre-existing conditions “no matter what.” Those who pay their own premiums are adamant they should not have to carry the weight of those who “refuse to buy their own insurance.”

They all agreed, however, on one important point: none of them really understands the complexities of health care reform, preferring instead to revert to positions about who should pay for it, who should have it, and ain’t it awful tropes. They know everything about Botox, including its high cost ($600 and up for a treatment) and don’t bat a Botoxed eye at “charging it.” Yet they complain about the high cost of premiums.

The truth is clear. People will gladly pay for what they want, but not for what they need. Protecting oneself from the devasting costs of a major illness is a “have to” not a “want to.” By separating these realities from the debate, we perpetuate the problem.

1. Take a lesson from the financial services industry, which has the tightest security and infrastructure to ferret out fraud, abuse and deception. Why can’t there be a clearing house of information available electronically that would house all of a person’s medical information in one place, updated regularly through the drug store, the physician’s office, or online by the patient and his/her caregiver?

2. When a prescription is filled, provide a color sticker of the pill that could be affixed, along with a description of the condition for which the drug is being prescribed. This way, the patient or his/her caregiver could assemble all the drugs onto one chart, with a place for dosage (i.e. twice a day, morning and night, etc.) so that the patient knows at a glance what to take and when, and importantly, why.

3. For new patients: Why not provide a log book for new patients, where the drugs, surgeries, allergies, etc. are all documented, and which could be brought each time to the office when the patient makes a visit?

4. None of the information currently written for patients is readable to older eyes, or eyes blurry from drugs or anesthesia or other treatments. Make the type larger for easier reading.

5. Review discharge orders, or medication plans with a view to user-friendliness. Make the instructions understandable, readable, and accessible. Better yet, have the patient write down the instructions given verbally, in their own handwriting, and have them read them back as they understand them. This way, the provider can see what they actually do understand, and correct any errors at that time.

6. Call the patient or caregiver within 24 hours to see if they have any questions and to ask about how they are. This gesture is both an excellent way to convey interest and caring, but also provides a chance to clarify any information the patient was either too overwhelmed or embarrassed to ask about.

7. Speak more slowly and carefully to patients. Medical jargon is often confusing and delivered with an avalanche of details. Patients find it difficult to absorb – especially so if the person talking is being abrupt, talks fast, or an accent. Young people often speak much more rapidly, often enunciating in a blurred fashion which makes it especially difficult to understand and track with what is being said. Slow down when talking with patients.

8. When a patient calls to make an appointment, the person often at the scheduling end is busy and not patient oriented. It’s important to understand that making an appointment with a doctor is not something one chooses to do, but has to do, and is therefore more stressed as a result. Show a little kindness, rather than just jump in to get the insurance and personal contact information. A pleasant person on the phone sets up a pleasant office visit later on.

9. Patients and caregivers are usually so overwhelmed when dealing with a major illness or medical problem. Between the paperwork, insurance forms, drugs, appointments, etc., the average person is frustrated and anxious. Why not offer, for a fee, to have someone help organize the details, set up the instructions, routine, supplies, etc.? Families would most likely be willing to pay for that kind of service if it would help organize their lives and reduce the burden on family members trying to cope with caregiving.

10. If you are a provider, remember that the medical environment is your life. You know the vocabulary of healthcare. But for a patient, or family member, the medical world is foreign and frightening. People often get angry when they are stressed and scared, and it’s important to understand that while you are caring for the medical problem, you also need to factor in the emotional walls that patients and their family members erect that can filter out your advice and set up an adversarial situation. Deal with the stress by acknowledging it, and the patient and family will be more reception to listening to you and complying with your recommendations.