A Physician's Take on the Affordable Care Act

Dr. Victoria Sweet was a physician for 20 years at San Francisco's Laguna Honda hospital, the last almshouse of the country. She spent time with complicated patients while getting her Ph.D. in history. The focus of her study was a 12th century mystic and medical practitioner, Hildegard of Bingen, whose approach Sweet incorporated into her practice of "slow medicine." For Dr. Sweet, "Medicine works best -- that is, arrives at the right diagnosis and the right treatment for the least amount of money -- when it is personal and face-to-face; when the doctor has enough time to do a good job, and pays attention not only to the patient but to what's around the patient."

Dr. Sweet wrote about her work at Laguna Honda, her study of Hildegard's medicine, as well as her pilgrimage to Santiago de Compostela in her book, God's Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine, which won the gold medal for nonfiction at the California Book Awards from the Commonwealth Club last year. I chatted with Dr. Sweet about her work, her take on the Affordable Care Act, and her advice to those who seek self-discovery. We're sharing her thoughts on the Affordable Care Act this week and will bring more thoughts from her on being a woman in the workplace, self-discovery, and navigating the healthcare system next week.

MB: Are you still practicing as a physician?

VS: I'm not. I always surprise myself when I say that. I thought I would be practicing by now. The book came out two years ago and I had imagined at best, if the book made a big hit, that by two or three months after the book was out I would be going back to Laguna Honda or getting some other similar kind of situation, and that hasn't happened. I've understood that there are policy implications and that it's helpful if I keep talking about what I've learned and give some ideas about what I think we could do to make things better.

I don't want to go back to Laguna Honda, I have to tell you. I really am fond of the old spaces. I think they're more human. And the new Laguna Honda is really beautiful. It's really a beautiful place and in many ways beautifully designed, but it's fascinating to see that the very privacy that required that the city build a new hospital has made everyone feel pretty lonely. So, everybody's in private rooms and they're beautifully done and beautifully kept and for some people it's a great place because of that, but for many people, they're just trapped inside their little spaces, which isn't really good when people are chronically ill or in rehab.

MB: Can you tell me a bit about your take on the Affordable Care Act? Where do you think it works and where can we improve it?

VS: I read the whole thing and took notes on it a couple of years ago. And the scary thing is that I don't think anyone else has read it. I think what the problem with the thing is, it's 922, single-spaced pages. So it's not really one law, it's hundreds of laws.

The thing I like about it is insurance companies can't pull your insurance if you get sick, so that's a good thing. I like the idea that there's something in there that says the insurance companies have to spend $0.80 of every dollar they get on actual health care. They can't only spend $0.60, which is what they've been doing. I like the expansion of Medicaid, although I have different ideas for how to do it.

What I don't like about it is [that] it did not solve the fundamental problem it was supposed to solve, which was that 50 million people in the country, more or less, don't have healthcare insurance. I think that in order to get the thing passed, they basically farmed it out to every single person who had a stake in it, and everybody got to write up what they wanted. Then they assembled it all as a law, and then they got it passed because everybody was willing to vote for it because there was something in it for everybody. But because there was something in it for everybody, it's a mess. I can just tell you as a physician, if we tried to actually make every single thing happen in it, we will be absolutely drowned in regulations and we won't be able to do anything.

In terms of what I would do to solve the problem of all those millions of people that don't have healthcare insurance, my idea would be, at this point, to simply add Medicare as a buyable possibility onto the healthcare exchanges. Medicare is actually incredibly efficient, considering it's government run. We always fear how terrible the government is and can't run anything, but actually Medicare is amazing. It only spends $0.03 out of every dollar on administration as opposed to $0.20 from the for-profit insurance companies. My idea is why not let people buy Medicare, if they want to buy it, and give them subsidies if they need it?

I can tell you the things other than the complexity that I really dislike, but I can understand why they couldn't get them. We're pretty much using the Swiss model in our country. The things that Switzerland does that were not in the healthcare act that make me crazy are 1) They have a mandate to buy healthcare insurance. The healthcare insurance companies have to sell you that insurance on a nonprofit basis. They can sell you upgrades of the insurance on a for-profit basis, but that basic healthcare insurance in Switzerland has to be nonprofit. And we didn't do that. So the insurance companies are charging $800, $900, $1,000 a month, and your deductible is $6,000. It's outrageous!

The second thing that Switzerland does that we don't do is that they control the cost of the pharmaceutical companies. So the example I'll give you, which just shocked me, is about Thalidomide. Thalidomide was sort of the star drug -- it was invented in 1958 as a sleeping pill, given to women all over the world who were pregnant, and it turned out it had terrible effects on fetuses and there was a whole epidemic of kids born with no arms and no legs. And in Europe they didn't notice this for a while, but there was an astute woman at the FDA who noticed it and she put a stop to selling it. So eventually Thalidomide went away. About 15 years ago, somebody revisited it and said, "Wow, if it does that to fetuses then maybe it'll do it to cancers." And it turned out to be an incredibly good drug, particularly for multiple myeloma. Amazingly good drug! So, they started using it and it's been around since 1958, so it didn't cost them anything to develop. Well, in our country they are selling it for $10,000 a month. In Mexico, they're selling it for about $5 a month.

So those are the things I don't like about it. I think the essence of the matter in terms of our healthcare costs is to let doctors see patients and spend as much time as they need to do a good job to get the right diagnosis and the right treatment.

You can find the finalists for the 2014 California Book Awards here. The winners will be announced May 5th and an awards ceremony open to the public will be held on June 9, 2014. Dr. Sweet also spoke at the Commonwealth Club about her book. Listen to her speech here.

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