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Interviews
Marc Babitz, M.D.
Division Director
Utah Department of Health
(And)
Director of Student Programs in Family Medicine School of Medicine University of Utah
Interviewer
Would you state your title Marc, and what your role is? I know you wear a couple of different hats.
Marc Babitz
Right now I have sort of two different hats; one here at the University--I'm a professor in the Department of Family and Preventative Medicine, and I'm also the Director of the Student Programs in Family Medicine, so we're responsible for the programs that mostly involve the medical students. We teach required courses in all four years of medical school, social medical classes, in the first two years family medicine, clerkship in the third year, and a public community project course in the fourth year and other electives and things. I'm involved with a little bit of teaching with our Physician Assistant Program and our Public Health Program. My other hat is with the Department of Health, and there I serve as the Director of the Division of Health Systems Improvement. That's a division that really looks at programs that have to do with safety and access, so we have some licensing programs, child care programs, and our office at Primary Care and Rural Health and our Bureau of Clinical Services among others that we have there.
Interviewer
Let’s start out with the broader picture. In terms of access, can you define what the problem is that we're facing? Are we in a crisis right now in terms of access for health care?
Marc Babitz
I think we really are in a crisis in terms of access to health care. I would say that I actually thought we were in a crisis 20 years ago with access to care, and it has only gotten worse during that time. We have barriers, we call, to access to care and each one of them makes a significant contribution to the problem. The barriers to care are financial, geographic--both rural and urban, cultural, including language barriers, and the availability of healthcare--the availability of the right kind of health care provider, and the times of the day or night that can be available. Those would be the four barriers to care.
So the biggest barrier that's talked about most of all is the financial barrier. So people can't get healthier because they can't afford it, and that would include of course they don't have insurance to afford it or they don't have enough money to afford it. We know that, for example in the United States, the last number I saw was up to 47 million Americans being uninsured. In Utah we have over 300,000 Utahans uninsured, and so these people face a barrier to health care purely financially.
Besides that barrier, unfortunately we have some insurance plans, which you know well, things like Medicaid and Medicare, and because those programs don't tend to reimburse health care providers as well, even having those insurance benefits may not guarantee access. Medicaid sadly would be the one of most concern if you will, for example, in Utah there is only a handful of dentists in the whole state that will accept Medicaid patients, and there are many physician groups that will not accept Medicaid patients because the reimbursement is so low. And if you follow some of the national politics, because the Medicare folks--we're talking about reducing Medicare rates, all the national physician organizations were threatening that physicians were going to stop seeing Medicare patients if the rates were going to fall and not keep up with inflation, so even having some insurance can create a financial barrier to health care. So that's the biggest one, but it's not the only one.
Beyond financial barriers, we have what I like to call geographical barriers. Now the classic geographic barrier, which is very prominent in Utah is the issue of being in a rural area--literally living somewhere where there aren't health professionals. We actually know when we look at physicians the vast majority of physicians choose to practice in urban or suburban communities, and we have a very small proportion, I believe it's about 5% of the total are practicing in rural America, and yet 20% of our population lives in rural America. In Utah, it's the same ratio. About 20% of our population live in 80% of our state, which is rural or call it the frontier areas of Utah, and there aren't physicians there. I was at a conference one time and I was talking about barriers to health care, and I got to this issue of rural care and this gentleman raised his hand and I said, "Yes, you have a question?" And he said, well Dr. Babitz, I understand that you're concerned about rural barriers to care, but after all, those people choose to live there, and I said, "Yeah..." We were actually having lunch at the meeting and so I said, "How's your lunch?" And he looked at me puzzled and he said its fine. I said, "Did you have a good salad?" He said yeah. "Did you like your steak?" Yeah, it was good, the potatoes were great. I said, "Where do those things come from?" And of course he named a grocery store chain, and I said, "How about before that?" And then he said, well they came from rural America. So I asked him, "Do you think the people who raised our food, mine our coal, produce our raw products... do they deserve to have health care?" Which point he thought well I guess maybe they do, and choosing to work there because that's where their work is, is not the kind of choice that I would think should deny you health care. So that's a rural barrier.
But sadly there are also urban geographical barriers to care. Urban barriers tend to relate more to where is health care located? Salt Lake, for better or for worse, presents a really good example of that. If you were to say start here at the University of Utah and draw a circle with maybe a mile or so radius picking up places like LDS Hospital, the VA Hospital, Primary Children's Medical Center, University of Utah Hospital, Salt Lake Regional Medical Center--all of the big clinics that are here--if you were to capture all of that health care, you'd find a very large percentage of the county's health care located in this northeastern corner of the county. But the question is where are the majority of patients who maybe really need access to health care? And the way I answer my own question, especially when I'm teaching medical students, is I say to the students, "When you're up in the University Health Sciences building in one of the upper floors, I'd like you to look west, and on a clear day you can see the people who need the care that we have here, but they're way over there, and how many bus rides is it to get to the University of Utah or to LDS Hospital, or to Salt Lake Regional? How many transfers? What's the cost to do that, and how do you do that if you have two or three children and one of them is really sick, and does that become a barrier?" Now there are health services on the west side, but not in proportion to the population that we would have in the east bench or the northeast part of the county. Other urban geographical barriers would include things like our health care systems, or doctor's offices or hospitals located on bus routes. Do they have adequate parking? Do they provide for things like childcare so someone can come and have their children cared for while they get health care? Those all become, what I would call geographical access barriers. So that's two, but we're not done.
There's a third one and it's huge, and the third is about culture and language. I personally believe that this country is as great as it because of our diversity. We have managed to take some of the best things from almost every society and every culture in the world. As people have come to American they have brought these wonderful things to add to the wealth and greatness of our society. But as people come and do that, and come to work here and contribute, they also bring beliefs about health care, and of course the languages may often be different. Now Salt Lake County is a great example of that also and again I love to, with students ask questions so the question I'd love to pose to people is, "Do you know how many languages are spoken in Salt Lake County as the primary language of the family?--primary meaning that they really don't speak much English and they really speak this language at home?" Now I didn't know this answer until a few years ago when the Salt Lake Tribune did a study of English as a second language in the public schools, and in their study they wanted to know how many kids didn't speak English and had a hard time learning, so they actually studied this and answered that question. What they found was that there are 67 distinct foreign languages spoken in Salt Lake County as the primary language of the family, and there are over 35,000 children in our public schools who spoke a foreign language, and these languages of course encompass all parts of the world. Now do those people deserve health care? They may have different feelings about health care and if they can't talk to the receptionist, or talk to the physician in their language, then how do they get health care? So that's another barrier that adds thousands and thousands more people into our system of access barriers.
And the fourth access barrier to care I like to call availability, and availability means two things; one is really it's of a practical thing is when can you get care? Now this is a tough one because I'm a physician and do I want to work 24-7? Well no I don't. In fact I like working 8 to 6 or 9 to 5 or whatever it is--usually it's 7 to 7, but I like those hours, and most doctors do the same. But people don't get sick between 8 and 5. They get sick at night time or on weekends, so what do we do then? Is regular health care available at those times? Well, what we know is, often regular care with your provider is not available at those times, so what we do is we resort to things like emergency rooms or urgent care centers. I'm thankful they're there. Thank goodness we have that option, but those are expensive systems of care, they don't provide continuity of care. Those systems may not have my medical records or my patient's records when they see them, and those become problems in the health care system--they reduce the quality of care. So available is an issue just of when we can get care.
The other availability issue is the kinds of physicians and health care providers and the number of health care providers that we have. I know mostly about physicians, so I'll talk about that. Within physicians we know that 70% of our doctors are in sub-specialties, and only 30% of our physicians are specializing in primary care fields--primary being family medicine, pediatrics, internal medicine, and to some degree obstetrics and gynecology. Well national or international studies actually have shown that the ideal mix of physicians is about half and half; half in the sub-specialties, half in primary care, and we know there is a significant barrier to the availability of a primary care physician for those who need that... we call it a medical home, or that kind of care, so that becomes a barrier to care. When a patient has to self-refer--when a patient has to ask themselves whether my chest pain... gee is it my heart? Or maybe it's my lungs, or maybe it's my stomach, or maybe it's my ribcage. Well gosh, those are four different specialties. Which one do I go to? When a patient does that, it makes it inefficient and a poorer quality health care system as opposed to a patient being able to go to their primary care doctor who can help sort that out, probably take care of it, and if not, refer them to the right source of care. So to me there are four clearly distinct access barriers, each one being very important as a part of the problem that we're dealing with.
Interviewer
In terms of the cultural barrier, different cultures have different medical models. How does that come into play?
Marc Babitz
The term we like to use in talking about culture is the word "health belief systems" which you talk about medical models. Health belief systems are very different. There is actually a wonderful anthropologist who did a description of the Western Healthcare System--what is the culture of our system? Which is very useful because you can compare it to how other people believe. A great example I had about that was a wonderful woman who was of Chinese descent. She had been living in the United States probably 30 years. In fact her daughter was my patient who spoke beautiful English and was very much part of the mainstream culture, but her daughter brought her mother in to see me about a particular problem. In deciding to treat the problem, I wanted to give the mother what was one of the newest and strongest medicines we have. Now it's interesting, and this anthropologist points out that newness and strongness are Western attributes of health care. We think if it's newer, it's better, which of course actually is not always true. And we think if it's stronger it's better, which actually is not always true. Stronger can mean more side effects and more money and things like that. So I wanted to give this woman this new strong medicine. She said no I don't want to take it. Do you got anything else? And I was sort of puzzled and I asked, "What do you mean?" And she said anything that has been around for awhile. I'm sorry it was a little bit late. And then I remembered my cultural training which said that many people of Asian backgrounds and Asian culture, they value tradition, they revere their elderly, they value things that are old, their healthcare systems like acupuncture medicine are 4,000 years old, so I said, "Oh my gosh, what a mistake I'm making." So I suggested, "Oh I have another medicine, same class of medicine, and it's very good and it has been around for only 30 years, but it has been around for awhile, would you consider that?" And she was quite delighted to have a medicine that had been around for at least that long, as opposed to the "new" stronger medicine. So culture and health beliefs are very important, and we have many other examples of that--whether it's hot or cold, and yin and yang and balance, and balance and many examples in different cultures where we have to be sensitive to other people's beliefs about what will help them get well.
Interviewer
It seems as if most of the public discussion is around the financial barriers to care, especially the uninsured. Are we under the impression or the myth that if everybody had insurance tomorrow, that the problem would go away?
Marc Babitz
I make a strong statement that I do want to qualify a little bit, but absolutely yes. If everybody had insurance tomorrow, there would still be a huge problem with barriers to care. The financial barrier would be gone, but the geographical, cultural/language, availability barriers would not be gone. We know that if you get insurance tomorrow and you start calling around to see a family doctor, most of them are going to say, "I'm sorry, I can't see you for days, weeks, months" to be seen. Our community health centers that serve the under-served have actually three months or so waiting periods. I found that one of the free clinics in Salt Lake County that serves the uninsured right now is running about a two and a half month waiting period to be seen, so there's a huge backlog of people in the primary care system and having insurance doesn't equal access.
Now, let me qualify that--I want to qualify it because I'm actually very supportive of Governor Huntsman’s efforts to bring more people into the insurance system, and I actually made the statement to the Governor, so I'll say this to you too. What insurance does is it allows people to build capacity. So if I'm a doctor in a clinic, and a third of, or let's say even 20% of my community has no insurance and I don't see them because I can't--the uninsured--I'm busy and I'm full, but I'm not going to try and expand my practice and hire new doctors because the only other patients I could see would be those who have no insurance, and I can't make money. But if you tell me today the other 20% of my community will be insured for the rest of their lives, now I can invest in a new building, I can buy more equipment, I can recruit more physicians, and I actually can begin to build the capacity to care for them. So I believe my statement is accurate that if everybody is insured tomorrow, it wouldn't solve the problem. If everyone was insured tomorrow, the problem would slowly begin to get better. Now, is it going to be perfectly fine after that? My answer would be actually no.
I want to go back to an earlier statement. In the United States today, only 30% of our physician providers are in primary care, so providing more access to people just through the subspecialties--having to self-refer, not having a medical home, not having a place to have primary and preventive health care really doesn't solve the access problem. Having more emergency rooms because there's more insured patients doesn't really solve the access problems in terms of having quality health care. So, yeah you can get seen by somebody, but that's not the true answer to the problem of quality health care.
Interviewer
A lot of people use the term medical home. What is a medical home?
Marc Babitz
A medical home is a place where a patient knows that they can go with any question or any concern, and that provider, whether it's the pediatrician or the family doc, or the nurse practitioner, that that provider will be there to listen to their concern and help the patient get on the right path of solving the problem. The right path might be a referral to another specialist. The right path could be care that's given there. The right path could be using a community service agency to help them, like a hospice agency for someone with a terminal illness. The medical home is the one place that you can go where you know that you will get caring care that may include referral to the appropriate sources.
Let me tell you a story. When I was a rural family doc in the beginning of my career, I remember this patient's story. This was a gentleman probably in his late 50's who lived in my little community. Many years ago he had some back problems, in fact he was disabled and couldn't work from that, but he hadn't seen a doctor for at least 15 years, and was living in this community and in a semi-retired lifestyle. He didn't exercise, he ate a pretty high-fat diet, he was overweight and he smoked. Now this particular gentleman awoke one morning with some pain in the left side of his chest and the pain gave him a little nausea--it didn't feel good. He told that to his wife who got appropriately very concerned and she said you might be having a heart attack and that got him more concerned, and he thought we better do something. What they did was, since they didn't have a doctor, a medical home, they opened the yellow pages, for a town that was 20 miles away, the big town, and they let their fingers do the walking until they found cardiologists. They called up a cardiologist office and said this is what has happened to my husband, what do you think? The office staff asked some questions and they determined they didn't think it was an emergency. He wasn't terribly short of breath. It wasn't severe pain. They said, look you put him in the car, he can't drive, you drive him down to our office and we'll see him. They drove 20 miles to the big town to the cardiologist, got seen, got a history, got a physical exam, got a cardiogram. The cardiologist did some blood work on him and said, you know it could be heart disease, I'm not sure, I don't see anything bad right now. I want to put you on some medication. I want you to stop smoking. Go back home, take it easy and I want to see you back in a couple of days and we'll go over all the lab tests and the results that we have and see what we have to do. The patient went home, took the medication. It didn't really help. He was still having this little pain, went back to the cardiologist two days later and went in there and said, “Well doc tell me… I mean heart disease? Do we have to do some kind of surgery?” The cardiologist said, “hey I got great news for you. It's not your heart. Your heart tests are great.” The patient said, “well that's great, but what do I have? “ And the cardiologist said, “I remember you telling me that that pain was worse when you breathe, you took deep breaths.” He said, “that's true, if I cough it really hurts more.” The doc said, “Well you know it could be your lungs. I have a colleague down the hall and he's a pulmonologist, he's a lung specialist. You might want to see him and see if they can help you.” OK, so they couldn't be seen that day so they drove back home, made an appointment, came back later in the week to see the pulmonologist, had a history, had an exam, had some lung tests that the specialist does, and the pulmonologist says, “well I don't see anything bad, you're a smoker and I wish you'd stop smoking and you'd have some changes from that, but let's get the x-ray back and get the final report and we'll see what you have and come back in a couple of days.” So they go back home, wait a couple of days, then head back to the pulmonologist. The doctor says,”hey I've got great news for you; it's not your lungs.” The patient says, “well that's great, but I have this pain.” The doctor says, “now didn't you say that you feel real nervous when you get that pain, that it is kind of upsetting to you?” And he said, well yeah. And he said, “Well you know, it could be stress. Now I have a colleague down the hall who is a psychiatrist and maybe you'd like to see him.” At that point the patient said, “I think I'm going to leave,” and he left. Now the patient at that point said, I think I'll just go see the family doc in my town… that was me. Make an appointment... so he comes to see me. Now every family physician should be so fortunate as I was to have a patient come in to see you who had already had a $10,000 work-up that eliminated the possibility of heart disease or lung disease. So I was ahead of the game from the start. But when the man came in, I actually did one thing different that my other colleagues hadn't done, because that's not their area of expertise. I actually poked on his chest, and when I poked on his ribcage at a joint here in the ribcage, he went, "Ow!" I said, "Is that your pain?" He said, "That's my pain." I said, "Sir you have something we call costochronditis; an inflammation of your rib cage. It's just a muscular/skeletal problem. That's why it wasn't your heart or your lungs. Here's how we treat that. Now by the way, I'd love to have you come back to see me because I am worried about you at risk for heart disease. I would like to talk to you about your smoking. I'd like to check your cholesterol. I'd like to talk to you about your diet if you're willing to come back and see me about that. But here's what this is, and this is how you treat it." So I had a patient who didn't have a medical home, who tried to self-select the right self specialist and did the best he could. He picked a couple of them. It just happened that it wasn't one of those problems, and after several thousand (dollars) over the testing, we knew what it wasn't, but he still had a problem that needed to be cared for.
The goal of a medical home is that lets start with the primary care provider, let’s sort out the variety of problems and then let me with my training, if necessary, say you know what? You need a cardiologist, or you need a pulmonologist, or you need a psychiatrist, that's possible too and let me help you with that and explain. So there's a difference. Now this is a story, it's an anecdote, but that's the issue where a medical home can become very important to people.
The lesson of the story is that a medical home is a place where you can have the majority of your health care taken care of and where when you need a referral, the referral is most likely going to be right to the appropriate person, to the appropriate specialty without guessing and without lots of money, and so the reason that most countries of the world have a majority of their doctors in primary care, and the reason that our nation even recommends 50/50 in primary care is to be able to provide just that service and not have the inappropriate use of sub-specialists, but have a medical home for everybody then we can appropriately use our sub-specialty colleagues and take advantage of their expertise.
Interviewer
Let’s shift gears here a little bit. One of the questions we’re looking at, and this has been raised by our state legislature…is healthcare a right?
Marc Babitz
I think that's a great question, and I think that's when people need to keep asking that question because it should be debated in public about that. I'll give you my opinion and I'll give you some background about it as food for thought. Let me give you the background first... some interesting background issues. Our Founding Fathers had a Declaration of Independence and a Constitution--in that they used an interesting phrase; the right to life, liberty and the pursuit of happiness. I don't know that healthcare has a lot to do with liberty, but it has a darn heck a lot to do with life and the pursuit of happiness. Being ill--chronically ill, being unable to get care effects your life and your pursuit of happiness. People who can't get healthcare already bare a disproportionate burden of mortality--that is early death, from preventable diseases. They are not being guaranteed their right to life that our Founding Fathers wished for them. Perspective... did they plan for universal healthcare? No they didn't, but it's interesting that they had that concept, so that's one thing that strikes me.
The second thing that strikes me in our nation's history occurred in 1948. The countries, mostly the allied countries who had won WWII were meeting to plan with the United Nations and they actually put together a Declaration on Human Rights and part of that declaration of all of these countries--I think it was 26 or 28 countries agreed to was that everyone had a right to health care, and so it was a human right that was to the benefit of society, it was to the benefit of all of the nations, and this was agreed to and actually signed by the United States in December of 1948. Since that time every nation that signed that declaration has gone on to provide some kind of universal healthcare for all of their citizens except one country, and that of course is ours.
Now when I say universal healthcare I'm not saying one model of care, because among the other countries, there are many different models. It doesn't necessarily have to be government run. It doesn't have to necessarily be only private or a mixture, but there are many models of how people have provided universal coverage for all of their residents. But in 1948 the United States agreed with the Declaration on Human Rights this was a human right. We have not fulfilled that agreement.
Another interesting historical tidbit, probably about 20 years ago--I think it was the 80's, I don't have the exact date --there was a lawsuit by one or more federal prisoners about lack of healthcare services in the federal prison system. The law suit went all the way to the United States Supreme Court and the issue really was do federal prisoners have a right to healthcare? The Supreme Court ruled that in fact federal prisoners do have a right to health care because according to our Bill of Rights which says that prisoners cannot have cruel or unusual punishment, the Supreme Court ruled that the denying health care to people was cruel and unusual punishment and therefore prohibited by our Constitutional Bill of Rights, and was not to be allowed, and since that time there have been marked improvements in the healthcare system in all prison systems. In fact people often get paroled early so you don't have to pay their health care costs if they're in prisons... an interesting concept.
Now if our Constitution talks about life and the pursuit of happiness. If our country signed the Declaration of Human Rights, everybody deserved healthcare. If our Supreme Court said that denial of healthcare is cruel and unusual punishment then why aren't we debating this issue? Why don't we discuss whether it's a right or not? My personal belief is probably already obvious, is that clearly it's a right! Humans cannot reach their potential as contributors to our society without the access to life and the pursuit of happiness, without a chance to have decent healthcare and preventive healthcare. People are denied years of productive life, they're denied years of caring for families and children when they can't have access to decent, timely, quality healthcare. So I do believe it's a right. People have a right to do that.
In our country we've decided that healthcare is a commodity. Healthcare is like new cars or clothing; charge what you can, make as much profit as you can and its o.k. Two of the most profitable industries in America in the last two decades are the health insurance companies and the pharmaceutical industries. But in a profit-oriented society where we deal with commodities, we say that's o.k. Now I'm actually a great fan of capitalism. I think it's great that we have to compete, whether you can buy a Lexus or a Mercedes or you buy a Ford or a Chevy... I don't care. I think it's great. I think it's great that I go to a clothing store and I can go to Penny’s and I don't have to credit shop at Nordstrom. It's great to have choice, and in that world we've seen a lot of benefits of this private sector free-market capitalistic society--a lot of benefits. But it doesn't work for everything.
The irony for me is our society actually already knows that. It's not a new thing, so I look at things called utilities; water. Our nation decided that human beings living in the United States of America should have access to clean water because it was important to their health and well-being--life, liberty and the pursuit of happiness. And so we have water systems, many run by governments, many run by private companies, but overseen by the public--public utility commissions, government agencies, and we actually make sure that people have access to water. You can't profiteer on water. You can't make outrageous profits. You can't have incredible C.E.O. salaries for the water company because water needs to be available to people at a reasonable cost. We have sewer systems. We have power supplies that we have government oversight of. We call them public utilities. We think that those things are so important for the well-being of our nation that the government should have some responsibility, even if it's just oversight, with the public to prevent profiteering, and it's not truly a capitalistic system as it would be for clothing and cars and things like that.
Now my question is why isn't healthcare at least a public utility? Fine, don't make it government run, don't make it nationalized, I don't care. Why isn't government at least a public utility? Why isn't somebody looking at pharmaceuticals, doctors, hospitals, insurance companies and saying, whoa... no you can't pay your C.E.O. a 20 million dollar bonus this year because that money they got was supposed to be buying healthcare. No you can't have a profit margin of X amount because the money you got for that profit margin is supposed to be buying healthcare. No you can't charge this much for this medicine because it only costs you pennies to make it, and no we're not going to fund your huge marketing campaign so that everybody thinks they need your medicine. I don't understand that. And so in my model, healthcare is clearly a right. We live in a country that said it's a right in many venues, and we're a nation that believes that some things like utilities... we do have to have access at a reasonable cost and we're willing to have government oversight of it, and so that's my question... why isn't healthcare at least a public utility?
Interviewer
Why do you think it isn't?
Marc Babitz
It's political will and it's power. When the Clinton's tried to reform healthcare, and there were a lot of problems with the reform plan, but the number one opposition to the Clinton reform plan came from a group called The Health Insurance Association of America. They ran big-time TV ads to convince the American public this was a bad plan. The ads they ran were factually incorrect when looking at the Clinton plan. It didn't make any difference. They convinced the American public this was bad and what they used was they said you're not going to have any choice who your doctor is, which is absolutely untrue but that was what they did. And the American public called all of their representatives and said I want choice in my healthcare, get rid of this plan, and they did. So those with a financially vested interest--those who profiteer in healthcare love the status quo. And the question is the will of the people... are we going to allow in this case profiteering taking precedence over healthcare for millions--47 million Americans? Is that how we're going to do it? Tough question, but it's doable.
Dr. Joe Jarvis, of the Utah Health Policy Project, has studied this and looked at this in many ways and he has shown how economically the universal health care system--taking out some of the profit administrative overhead is actually cheaper. He's demonstrated mathematically how there's already enough money in our system to care for all of those who need healthcare if we just had a will to spend it on heath care and not spend it on C.E.O. bonuses and profit margins and stock benefits and things like that.
Interviewer
In Utah what are some of the proposals on the table?
Marc Babitz
The biggest one, and again I am a supporter of this, has been the Governor's plan to try to look at how can we extend insurance to more Utahans and this year? Our legislature did pass the expansion of the SCHIP, the State Children's Health Insurance Plan Program; so many more children will be eligible to get a Medicaid-type coverage. I'm hoping they'll be enough capacity among Medicaid providers to take these children and I think there will be because again I fear that just giving them insurance may not actually equal access, but I think for children there's enough family docs, pediatricians, health centers that will take Medicaid that will work out fine and I'll be thrilled to see another 12,000 children have health care.
Also looking at the insurance industry to look for other kinds of plans... plans that are more primary care preventive plans that maybe have lower rates that don't deal with the catastrophic things that might be appealing to younger families, plans that have higher deductibles and things, a little bit more of a cafeteria approach to insurance, so looking to insurance solutions that might make insurance more broadly available at lower costs to those that could a different plan. Right now you're kind of locked in--you may have just one choice, two choices, maybe have very few choices about what you have with insurance which is interesting because in our capitalistic society we actually value choice. How many hundreds of car models are there out to buy? But when you look to buy health insurance, we're not talking about the same kind of options available to people, so I think there's some chances to expand that.
Short of those things then, there are other plans. I'm aware of plans to actually seek funding to expand our primary care healthcare clinics and this funding could be a combination of public and private partnerships--the government taking a responsibility into playing a role, but also looking for private partnerships and that, but actually to build the capacity, build the access points in a medical home-type setting to be able to care for people as another way to do it until we get everybody covered by some kind of insurance until there is enough capacity.
Interviewer
Are we unique in Utah? Are we uniquely somehow in a position to find a solution to this problem?
Marc Babitz
I think in many ways we are. I think there are many things about Utah that says that we have a great deal of concern about the welfare of our fellow community members. I think that's a real good quality of our state. We're in a state that does promote good healthy behaviors in many ways as it relates to smoking and drinking, things like that. We're in a state where we have seen a lot of public/private partnerships work together to accomplish things. So those are all things that suggest that some of these models could work and I just think it's the challenge of us standing up to say you know, this is just not an area where profiteering is useful. We have to accept that. We have to begin to back off from that model and move toward a model that really assures better and more access.
Interviewer
Another group who sometimes you hear people complain about is the undocumented, and there are people who say, why should my tax money be going to support these people? What do you have to say about that?
Marc Babitz
There are a couple issues for me about whether we treat people who are undocumented or not, citizens or not, have visas or whatever in the country. First issue is more of a policy one which is people only come to this country when they have opportunities to work and better their lives and make things better. We could end the problem of undocumented rapidly if we had the willpower to say we're going to rigorously enforce the employment laws. We're going to go out and start busting employers for hiring anybody who is undocumented. We're going to have penalties and fines and jail-time for those contractors who hire people to paint and build and the meat-packers and the hotels who hire people to clean and do dishes. We're going to fine them and put them in jail and we're going to rigorously enforce the employment side of it, and if we shut off the jobs, people aren't going to come. Why would you come thousands of miles when there's not work? It wouldn't happen. Now why do employers hire the undocumented people? Because they can get them cheaply, they'll work for less money than a "citizen" will work for, and if we allow that to happen, then we have caused the problem, and if we're going to have the will to not want the undocumented in our nation, then the way to stop it is through the employment side and to make sure that employment wages are adequate enough that citizens will take those jobs and will do those jobs.
Second point, is that the vast majority of the undocumented are in fact working. Now that means that they're actually contributing to the benefit of our society--the people who changed your linen in your hotel room, people who washed your dishes in the restaurant, people who came and painted your home, people who mow your lawn and your grass, people who do services that we as Americans want, they're doing them. They're contributing to the life, liberty and the pursuit of happiness of our society, and to say that it's o.k. to do that but you don't get the other side of the coin, you don't get the other benefit--you can't go to the library, you can't get health care; you can't have a driver's license? That seems nonsensical to me. That seems to be incredibly prejudicial about another group.
Then the third reason is a very practical medical reason. So someone from another country comes here and they're working at a hotel in the kitchen or restaurant or changing the linen and they happen to have tuberculosis. Now tell me, would you rather have that person get medical care to treat their TB or would you like to have them coughing up and down the halls of the hotel spreading tuberculosis among these citizens who happen to have been born here? Denying care to undocumented people puts the rest of the society at risk for illness that could be spread, TB just one example, HIV, sexually transmitted diseases, other infectious diseases of course would be the classic ones, and denying anyone with chronic illnesses means that at some point an undocumented person may end up in an emergency room, and by federal law they will have to care for them for this emergent condition, so we have chosen to spend a whole lot of money through the hospital system to care for this heart attack, stroke, advanced cancer because we wouldn't allow the person to have preventive care or early treatment to prevent the crisis. So from a practical heath care point of view, it makes no sense to me either. So for those people, who advocated that we shouldn't have the undocumented in our society, please go after the cause, which is the employment side.
Interviewer
I'm lucky. I have insurance. Why should the insured care about the issue of the uninsured and access to care?
Marc Babitz
If I was insured, and I am like you, I should be looking at the data that shows in our country; well there were 20 million uninsured, then 25, 30, 35, 40, 45, 47. The trend is absolutely clear. The fact that you have insurance today, looking at the trend, is not guaranteed you're going to have it tomorrow. If I was working for a small employer, I'd be really nervous. Small employers use to provide health insurance. As business gets tight, profit margins tight, one of the first things they drop is health insurance. I'd be really nervous. Your boss could decide tomorrow that health insurance is no longer a benefit. So I'm safe and I work for a large employer, and yet the co-pays and deductibles may be going up so much that you can't pay it. We've seen situations in large employment where your cost of living raise was barely enough to pay the increased premium cost for your health insurance. At some point that won't work for you. You can't... then you're sliding backwards on your economic scale and you may decide I'm going to drop my health insurance so I want the money to pay for food and clothing and transportation and things, so everyone who is insured is unfortunately at risk of losing insurance, and the trend is clear. There's no doubt that's the way it's going. It's not getting better; it's getting worse, so you ought to be nervous.
And beyond that, there's another reason--we know that something like, I think it's half of all bankruptcies in America today are due to medical costs. If you look at your insurance policies you'll find that they all have limits. They only pay so much for you know depression and suicide and psychiatric problems and so much for hospital care and things like that... they have limits, and everybody even with insurance is sadly at risk of expending your limit. The horrible cancer that your child gets and you do everything in the world, every doctor, everything you can to help them be cured and be satisfied and all of a sudden you just find out that you've reached the limit of your insurance... now what? Well you had/have insurance but know one covers that particular issue, and everyone who has insurance is at risk of that. We all go through life hoping that a) I won't get really sick, and b) if I do get sick I'll have insurance coverage for it. But the national data would suggest that it is getting less and less every year, so even those of us who have insurance should be concerned. But that's actually being concerned for a personal reason.
I'd actually like to suggest a higher reason. Do we care about our fellow human beings? Do we care about our neighbors? Do we care about the people who make our lives possible by being part of the society, contributing to it and doing that? Because if we do, then we ought to care whether they have healthcare. We seem to care if they have water or sewers, but do they have healthcare? We ought to care about that. I care deeply about it. It troubles me that people who are just as human as I am with the same soul and spirit that I was given might suffer needlessly because of a lack of healthcare. That bothers me. That alone should be enough reason for those of us who are insured to know that it's not right. It's wrong to have 47 million uninsured Americans.
Interviewer
Do you think that people really understand how much people are suffering out there?
Marc Babitz
I don't. We hide it well. News has taken up with the most recent traumas of the day; murders, shootings, vandalisms, robberies, car accidents, airplane crashes, things like that. But we don't talk about the carnage of people who die and suffer because of the lack of health care and there are stories all over the place about that, and many, many people can tell you stories, I can tell you stories... they're there, but they don't make news and so people don't hear about it, and so you go through every day and like you say, if you have insurance then I'm okay. I don't worry too much about other people.
It's interesting... I mean even things like food is better handled in our society. We have campaigns for food. We have food banks. People donate for food. The post office collects food, the boy scouts collect food. We do a lot about food because we know it's important and we give from our hearts because we want people to not be hungry because it hurts to be hungry. It's not healthy to be hungry. But somehow we don't have the same thing going on about healthcare. Nobody is out there collecting bags of healthcare... I'm saying they're the same problems, so it's really to me an issue about not being in the forefront of the public's mind. Now of course doing this documentary is a great thing to do and in the next presidential election I think health care will be right at the front of that. Besides the war in Iraq, health care will probably be number two issue on people's minds.
Interviewer
They say it will be the number one domestic issue. I want to move into the safety net system because we're going to be examining that a lot. I want to start with an overview basically of what is this safety net. Define that for me.
Marc Babitz
The safety net has been defined as healthcare providers who care for those people who would traditionally have a barrier to care; the uninsured, Medicaid patients, people who are culturally or linguistically outside of the healthcare system, or geographically you know outside of the healthcare system, or geographically, so any of the barriers we talked about--financial, geographic, cultural unavailability there are providers who are addressing those barriers to care for those people who are outside of the system. Most of it is the people who are uninsured or maybe have Medicaid as their insurance would be the biggest thing, and then also our rural providers, so that would be described as a safety net. The safety net is a very important role and I'm very thankful that it's there because I know that they limit human suffering. The problem is the safety net isn't big enough and a net is a good example. A net catches a lot, but a lot goes through and that's what's happening. We catch a lot of people, we help them, but a lot of people still fall through the holes and the net. It's not a perfect system, so thank goodness we have it, but it's not perfect.
There are some prominent people in our nation's health care world who actually have stated that having a safety net is a mistake because having a safety net allows the society and our government to avoid taking responsibility for this huge problem of people not having health care. So we keep doing this patchwork quilt of helping folks and it takes the pressure off society, government, whatever to actually do something about it. Now I don't know, for myself seeing the suffering day to day I'm not willing to say that. I'm not willing to say let's just close the safety net off, let those people just suffer so their suffering will be so bad that we'll force something to happen. That's just not human to me, so I'm thankful for our safety net and I support our safety net. I'd like to expand our safety net and like to do it concurrent with breaking down the other access barriers; dealing with financial barriers, dealing with broader coverage and so on.
Interviewer
So are we doing enough as a state right now to support the safety net?
Marc Babitz
Well I guess I could say that you can never do enough, I mean you can never do enough. There's probably not enough money to do enough and deal with education and transportation and so on. Our state is doing a good job. Is it perfect? No. Are we improving? Yes, this year another half a million dollars was put into the pot for our primary care program. We do have the state run clinics for people with Medicaid and Primary Network Coverage. So we're doing a lot of things from the government point of view. Is it enough? No. There are still people who are not served. Will we continue to work with the state legislature and the Governor to try and see if we can add more? Yes we will. The Governor was very supportive this year of these programs like expanding the CHIP program, the Primary Care Grants Program, so we want to keep doing those things and I guess what makes me feel good is I know we're going in the right direction. We're not falling back, we're not getting less, we're actually doing more and we're expanding. It's slow. I wish it was faster. This proposal I mentioned earlier to provide more comprehensive primary care is a big proposal. We're talking in the 25 million dollar range to do something like that. That's a big leap--probably more than we can do in a given year, but if we did it a little bit at a time, so I think we're making incremental move toward improvement, and that's a positive thing for me. I guess I get mostly frustrated when I see nothing happening and no action. But I do see awareness. I do see many people with a desire to do something and I do see us moving forward and those are positive things.
Interviewer
One thing that I discovered is that the State of Utah gives less money to Community Health Clinics compared to the national average (about a quarter less). Why is it that we as a state don't put more money into CHC’s?
Marc Babitz
My assessment of that would be a couple of things. Number one, this is a state that prides itself on being conservative and I don't say that as a negative phrase, I think conservatism has value, as liberalism has value, but this is a state that has been fiscally conservative. I think that has shown that it has been good in many times because it has helped us get through tough times, better than maybe other states have gotten through, but our state is a little cautious about how we spend money, making sure we plan for the future, making sure we don't over commit ourselves. We have limitations on our budget. There are past limits on how much we can do in each year's budget, and I don't really fault those things. I understand why they're there. And then we have competing demands. Utah, for a lot of reasons is ranked very low in education funding. It's ranked low in transportation funding, that's like mass transportation, and ranked low in terms of health care funding. So there are a lot of big things out there. I know from the last legislative session and other ones I've been to that the disability community, for example, is always very vocal about the lack of support, that we still have a waiting list--people who get on help with their disabilities and things.
So there are lots of needs and every year I actually don't envy legislatures getting requests for many times more money than there is even with a surplus is more than is available. So I think people are making difficult decisions in the best way that they can. I don't really fault them. I think its incumbent upon those of us in the health field to work hard to make a better argument. Why we're as important, or more important than transportation or education at any given point in time... that's always the challenge. I think we made a real big leap with education and transportation this year, so I'm hoping that healthcare will maybe rise a little higher wrung a funding priority next year. I don't know whether priorities will be springing up, but that's my hope as we take care of one problem and move to another one, so I'm going to be optimistic about that.
When states have invested heavily in community health centers and these underserved things, there has been something that has gone on that's really helped them have a banner year budget wise, as well as that political will that this was the number one problem in the state at that time was health care. I'm thinking like things that happened in Indiana for example, when they put a lot of money into the community health centers. So we need those two things to come together. We need to have some banner years of income for the state, and we need to move health care up to the top... things like your documentary. I'm very hopeful that it will stimulate public interest and public debate on this issue and help raise more awareness among all of the public, including the legislature, about the needs and perhaps if we have a banner income next year they will be able to address this issue more strongly in the future.
Interviewer
What's your biggest frustration in this issue?
Marc Babitz
My biggest frustration is that I know that people hurt every day. When I work in a clinical setting with the underserved, I don't do a lot of that anymore, but when I go to the homeless clinic or we do our Care Fair in the summer and you look in the eyes of someone, or the parent who can't get healthcare for themselves or their child and you see the suffering that they have and you know it's preventable, that's what bothers me every day. I understand the complications of political will. I understand the complications of budget, but it's looking into the eyes of the individual who suffers... that's what's hard. That's the hardest thing for me.
The second hardest thing I suppose is explaining and have people understand what it means to not have health, what it means to not be able to pursue life and happiness and things in a fair way and to have them understand that in a way that's prioritized with other kinds of things in government, so that's probably the second biggest thing to explain that people understand and makes sense and would allow them to commit to making a change. ... People suffer, you know. When I suffer when I have my back problem, I go to a doctor. I get surgery. I get a new life. If I didn't get that surgery I wouldn't be working today. I couldn't be on my feet for more than five or ten minutes at a time without my legs going numb. My baby, she's ten months old now. When she was two months old she got a kidney infection because of a little birth thing that probably will get better, but the kidney infection turned out to be a very nasty bacteria. We got a call in the middle of the night after getting the test and we thought she'd be fine and took her home. We got a call in the middle of the night saying come to the hospital immediately because your baby has to be put in the hospital, needs IV antibiotics and things. She did fine. She was there for four and a half days, but the miracles of modern medicine and great antibiotics and a wonderful children's hospital and great providers, she's fine and she's doing well and hopefully we'll get her tested and her kidneys will be all back to normal and won't even have a risk of problem in the future. While my baby was getting well, I couldn't help but think of the babies that I have delivered or taken care of in the past who didn't have insurance, and that means they wouldn't have gotten the call at midnight saying come to the hospital because you have to be admitted. They wouldn't have had the blood tests that my baby had to find out the problem, and in my baby's case, if those babies had what those babies had, those babies would be dead. My baby is alive. Now that's not right, and that's because of lack of health care. So I take it personally, yeah, I do.
Interviewer
And in the rural setting we were talking about that there are people in rural America who are suffering and I'm just thinking of the ranchers out there; the part-time hands. What are some of the problems and difficulties that they face?
Marc Babitz
It's really just the lack of providers is the biggest thing. There is just a lack of people to care for them so they develop a culture of you don't go to the doctor, and it's sad that the culture is expensive, you have to wait, you can't get in, I have to go during work hours, I just don't go to the doctor, I just get by the best I can so I don't get medicine for my high blood pressure I just then have my stroke. I don't get my cholesterol done; I just might have a heart attack earlier than I should have. I don't get these problems treated because I just need to tough it out. It's an interesting dilemma because as having practiced in rural medicine for nine years and being in my career, I have tremendous admiration for much of rural culture. I admired my patients and their, I would call their toughness; emotional, physical toughness. We had a story from a medical student who went to one of our rural communities in Utah recently and came back and talked about a rancher who was loading cattle to go to market and had to get it done, and he needed to get it sold and all of that, but he was in the chute when this cow decided to lean against him really hard-- cracked like three ribs, he heard them snap, he was a little short of breath. It hurt a lot to breathe, barely could stand up, what did he do? He kept loading cattle all day long, and when the cattle were good enough to market, he went to the hospital, you know, and the treatment... what do you want to do? We don't put pins in, we don't split it, and you know it will be a pain medicine. He said, I don't need that, its fine thanks, just make sure I'm o.k. If the lungs are fine, that's alright, then I'll go back home--that's the rural mentality. I admire that. But sadly that same mentality says high blood pressure? Ah heck I'm not worried about that. So they have a stroke. High cholesterol? Ah heck, I don't need to worry about taking... 'till they have a heart attack and so on. Cancer screening? I don't need that 'till they have colon cancer. So that rural toughness is great, but it needs to be combined with adequate access to primary and preventative healthcare so that we can keep those folks doing what they want to do and growing our food and mining our coal, and getting our raw materials, and manufacturing things we want so we can keep them healthy to do that and not have them suffer.
Interviewer
You talked a lot about what's wrong. You talked a lot about the frustration. Do you see any hope in all of this?
Marc Babitz
I'm optimistic, yes. It's my human nature, so the answer probably relates to my human nature than the problem. I have always thought there was hope. I have always thought we'd have a will to solve it, and I guess the sad thing for me is that I thought that 20 years ago we would solve it. I thought it was bad enough 20 years ago, that something would have to be done, and it hasn't--it has just gotten worse. But I still believe we can do it. I still believe that we have the will. I still believe that we have the humanity within our society to do something about it. I do think it's possible and I think that we just have to, you know, keep talking about it, keep it in the forefront of the public's eye, and keep moving forward with that political will.
Interviewer
Is there anything you would like to add in this issue that we haven't touched upon?
Marc Babitz
The only thing that we really haven't talked about, which really goes hand in hand with building access and capacity, is the issue of quality, and there's a lot of talk about quality and healthcare. There has been a lot of publicity about errors in healthcare and how we actually hurt people in the healthcare system. So one thing I would ad is that any plans to expand access and expand capacity need to be done in a quality fashion. I mean like the medical home, as an example, the people get better results when they have a medical home than they do otherwise, and so we have to be keeping those two things hand in hand, and that's why I say just giving people insurance may not be enough. I mean insurance is what we have when we have all of these medical errors and we're doing things to correct that. The other thing that I'd add is that quality of care is also important and needs to go hand in hand with expanding access to care.
Interviewer
It's interesting too we are leaders of that in this state.
Marc Babitz
We are.
Interviewer
I'm trying to succinctly define the problem that we're facing in America in terms of healthcare. Is there a way to very succinctly define that for me?
Interviewer
We have allowed a huge percentage of our population to be denied health care, and thus in my opinion, denied the right to life and the pursuit of happiness, providing cruel and unusual punishment for suffering for things that they don't necessarily have control over, and in a society like ours that believes in human dignity and human rights and will fight overseas for that, it's not right that we don't address healthcare because it's the same kind of battle, same kind of problem.
Interviewer
And in terms of healthcare, is it pretty much the uninsured and rising costs? Is that what our biggest problem is?
Marc Babitz
The uninsured is the biggest part of the problem, and the cost plays into that, but I think we always have to remember at least the four barriers, but at least the top three; financial access barriers, cost, which is the cost and lack of insurance, but geographical barriers that in equal distribution are providers in rural and urban areas, as well as the type of providers, and then the culture and language--recognizing that part of the greatness of our society comes from the diversity and we have to have diversity of healthcare delivery. We have to be prepared to talk to people who don't speak English, for example, to provide health care. So I would keep in mind at least those three barriers.
Interviewer
How do we compare internationally?
Interviewer
Oh, that's unfortunately a sad question and a bad answer. It was actually answered in 2000. The World Health Organization undertook a major study of all of the major nations of the world to identify healthcare and to rank them. Now people love to debate the ranking system, and that's fine. The ranking system looked at a lot of things; how much money you spent (we're number one in that), looked at like, you know the number of physicians, it looked at a lot of things, but also the health outcomes; how good your infant mortality rate was, how good your life expectancy was, those kind of things too. It looked at how satisfied you are with your healthcare. It looked at access to care, those kinds of stuff. So among many, many ratings criteria, the World Health Organization ranked the United States 37th in the world--that's bad. If we look at things like infant mortality, just infant mortality is how many babies basically die in their first year of life, and our nation with all of our wonderful things, we should be fabulous. We're actually, in the last years, been between about 22 down to 28th in the world in infant mortality. There are Central American countries that have better infant mortality rates that we do. That's sad. In life expectancy we're usually around 16th or 18th in the world in life expectancy, and get all of the wonderful things we have, I think we could live longer. The Japanese have the highest life expectancy in the world, and they smoke a lot. But something's going on over there around healthcare and maybe other things like diet and things that helps them live longer, and they also do have more universal access to care than we do. So when you look at world rankings on various studies, we don't do well, and we do have the most expensive health care system in the world. In 2005 we spent 1.9 trillion dollars on health care, so we're probably easily over 2 trillion now, and that was averaging about over $6,000 for every person living in the United States--huge numbers, way more than any other nation in the world. But we're not getting the results. For that price, I want the Mercedes for that price. I want good results. I want good life expectancy. I want good infant mortality. I want better rankings. I don't want the other car brand name healthcare system for that cost.
Interviewer
So what are we buying with our money?
Marc Babitz
We're buying the most expensive and the newest care for a few, and not providing the basic reasonably expensive care for the many. So these people who have good insurance and buy these fancy brand name drugs and have all kinds of surgeries and things like that, whatever they have, that's great, but other people can't even get pregnancy care, can't get well-child care, can't get immunizations, can't get cancer screening, can't get their high blood pressure treated, and so we've decided to make that trade. I think that's a horrible thing to do. What a horrible trade to do.
