© Jack Cashill
Published in Ingramsonline.com - September 2011

Spend a few days in a hospital bed and you'll fully appreciate what we've got—and understand what's putting it in peril.

For the last twenty or so years I have been talking about health care systems, researching them, writing about them, even marketing them, but I learned more about American health care in a few days this summer than I had in the last few decades.

In the way of background, I spent a week at the New Jersey shore in mid-July with 60 or so of my closest relatives. Although the numbers shift, we have been coming to this same honky-tonk stretch of shore every summer since I was no bigger than a slice of boardwalk pizza.

Up until a few years ago, I thought this the most interesting place in America no one knew about. It is still interesting, but it is no longer unknown. Snooki and pals have put Seaside Heights on the map. The week we were in town, so were they.

On the last morning of our stay, a Saturday, I woke up woozy and unwell in a room blasted by a funky air-conditioner we had installed the night before. I was scheduled to fly out on Sunday so I spent the evening at my sister’s place up the coast. For dinner, I felt just well enough to eat. We had clams.

I woke up the next morning deeply miserable. Think George Gipp in the last scenes of the Knute Rockne Story, but worse. The Gipper could luxuriate in his own bed. I had to make it somehow to Newark Airport, renowned only for its chronic flight-delays, and from there on to KC.

I chose to go for it. Having New Jersey’s two largest hospitals as clients in the 1980s, I knew the difference between care here and care there. There, hospital staff greeted health care’s customer service revolution about as eagerly as Khadafi greeted the Arab spring.

Once, I watched a cafeteria worker jump over the counter and slug a visitor who criticized the service. At the time, the hospital’s marketing director turned to me and said with a wry smile, “Welcome to New Jersey.”

Still, for all its rough edges, when compared to the French hospital where my two-year-old had been treated earlier that decade, this New Jersey hospital was the Mayo Clinic.

Enough history. I desperately wanted to get home. When the Continental express jet landed in KC without my having forced an emergency landing or even called “Uncle Ralph,” I offered prayers of gratitude to God and every saint I could remember.

Once home, however, not even my dependable Alka Seltzers helped. I felt like I was going to explode. I imagined headlines like those I saw in the National Enquirer of my youth, “ Kansas City man self-combusts, bursts into flames in upstairs Lazy-Boy.”

Home alone—my wife was in Europe—the thought dawned on me. Hey, I have health insurance. It is late on a Sunday night. There is a major hospital three minutes away. Why sit here and blow up when I can drive there?

So I did, all the while thinking how pleased I was to be able to do so. I parked just feet from the door of the Saint Luke’s ER and walked in. I expected an endless stay in ER Limbo, but instead I was greeted like one of the elect at the Last Coming.

Within minutes, I was sitting on a bed taking to an honest-to-God doctor. All he had to do was hear the words “clams” and “ New Jersey” in one sentence, and he had a suspect. Still, when I argued for the clams’ innocence, he listened. Throughout my stay, the diagnosis would prove to be a collaborative process.

While I waited for the test results to come back, a business manager approached and asked apologetically for my $100 co-pay. I tried to reassure him. “No problem,” I said. “It makes much more sense to collect now than any other time.” I paid in cash. He seemed pleased.

I did not do well on the tests. My blood pressure was too high, and my sodium level—I did not previously know I had one—was way too low. The doctor told me I was staying.

The business manager returned, even more sheepishly. My co-pay for a stay would be $300, but he would roll the $100 into the $300, and I would only have to pay $200 more for the whole megillah.

If there is any one point at which our health system goes awry it is right here. With the costs now vanishing into a black hole, I no longer had a reason to be rational in my requests for care, and the hospital had no inherent reason to deny them.

Given our mutual incentive to indulge, managed care companies have stepped up to constrain us. Unlike the doctors and I, however, they play no role in the diagnosis and have no real stake in the outcome. Whether I live or die does not affect their bottom line.

The solution is obvious enough: put the patient back in the decision making process through some variety of medical saving account. Had I money on the line, I might not have chosen to stay. I almost assuredly would not have stayed the four days I did, and I likely would have passed on the CT scans. These might not have been wise decisions, but they would have been my own.

Given the relentless cost spiral, rationing is in all of our futures. If someone is going to ration my health care, I would rather it be me. Those not paying their own way can queue up like their brethren in Europe and Canada, grab a number, and hope for the best. Once in the door, they can remind themselves that care in a “ward” can be just as good as it is in a private room.

Do not be mistaken. The care at a hospital like Saint Luke’s is hugely better than it is in the nationalized systems we are asked to envy. During my stay, everyone I saw was competent, efficient, polite, even charming, and I don’t think it was because I had the best tan in the stroke unit. (There being no “clams” unit, they had to put me some place.)

With my condition stabilized, I argued my way out after four days. The docs would have like another day or two to nail a diagnosis, but as an independent contractor, no one was paying me to lie in bed and watch Turner Classic Movies.

Although we identified a thousand things that were not wrong with me, we never quite figured out what was. I blamed the air conditioner. The docs leaned toward the clams. We all agreed, however, on thing: I could have only caught whatever I caught in New Jersey.

Who is Jack Cashill?