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Health vs. Insurance
We should focus less on insurance and more on outcomes.


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‘I am happy to say that she is holding her own.” So said Dr. Michael Lemole, section chief of neurosurgery at University Medical Center in Tucson, on Tuesday, characterizing the condition of Rep. Gabrielle Giffords. “She is able to generate her own breath.” So these are the small victories that Representative Giffords, shot in the head by a lunatic on Saturday, now can look forward to, as she begins her long road to recovery.  

Now that the initial shock of the tragic shootings in Arizona has subsided, the rest of us might pause to consider some lessons for our health-care system that the Arizona tragedy might provide. After all, as a nation, we have spent the better part of two years now wrangling over national health insurance — with no end in sight — and yet over the weekend, we were just reminded of what really matters in health care: health. Yes, health is what matters, as distinct from health insurance. And health insurance is a function of the health system; the insurance card is only as good as the professionalism and technology it is connected to. As a member of Congress, Representative Giffords was always entitled to health insurance, but what she needs right now is the best-quality care.

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Health insurance, in a way, is symbolic, like paper money: Health insurance has no intrinsic value; it’s valuable only if you have a good place to “spend” it. So health insurance in a Third World country tends not to be worth much, because the health system itself is so poor. By contrast, health insurance in a First World country is worth something, because that insurance entitles one to high-quality care — care that is paid for, of course, out of the overall economic surplus of the country, augmented by economy-wide technical skill. So once again, it’s not the health-insurance card that saves your life; it’s the health providers, backed up by the rest of the economy.

To illustrate, we might consider the sort of care that any cranial-gunshot victim — not just Representative Giffords — might receive in the U.S. Here’s a typical scenario for a quality health-care system:

The patient receives CPR on the spot, if need be, and is endotracheally intubated as an automatic precaution. That is, a breathing tube is inserted to ventilate the lungs and also to protect the patient from pulmonary aspiration — foreign material getting into the lungs — or regurgitation. Unless the patient scores extraordinarily low on the Glasgow Coma Scale, the patient is sedated so as not to react to the tube, which, of course, is extremely uncomfortable. Endotracheal tubes were originally made from latex rubber, but most modern endotracheal tubes are constructed of polyvinyl chloride.

On the scene, or perhaps in the ambulance, the patient receives saline solution to stabilize vital signs. A brain-injury patient needs a certain minimum of cerebral perfusion pressure (CPP) to maintain oxygenation. If CPP falls too low, the brain tissue becomes ischemic and devitalized — that is, the patient becomes brain-dead.

In the ER, the main tasks are to stabilize the airway, normalize vital signs, and control external hemorrhaging. So in addition to checking the intubation, a blood transfusion may be necessary.

Next, the patient receives a CT scan to locate the bullet and assess the damage. If the CT reveals active bleeding or a hematoma, for example, a craniotomy is necessary, in which the blood flow is suppressed and the clot evacuated. Even in cases where the bullet passes through the victim’s head — as happened in the case of Representative Giffords — the doctor must still locate not only clots, but also bullet fragments and bits of bone. The medical term for a foreign object in the body is nidus (Latin for nest); if possible, these nidi will be removed to ward off infection.



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