Posted on July 6, 2009

A doctor fights for a single-payer plan


By Elizabeth Strother
The Roanoke Times
June 28, 2009

Dr. Janice Gable knows a lot of uninsured Americans. They became part of her family back in Konnarock, a village in the Appalachians where the mountains of far Southwest Virginia roll seamlessly into Tennessee and North Carolina. She practiced medicine there for 34 years.

Those years made Gable an ardent advocate for health care reform — and no half-measures, either.

She thinks nothing less than a national single-payer, private-provider system like Medicare is needed to replace one that delivers the costliest health care in the world, gets far from the best results and leaves so many hard-working people uninsured.

She knows their lives.

“In Konnarock,” she says, “people mostly took care of the disabled at home. But for someone to quit her job at the factory to stay home and take care of Dad — well, she can’t have health insurance.”

Then there are people like Roscoe and Vicki, the husband-wife auto mechanics who were self-employed, and so had to make a choice: “either have no insurance, which is how they handled it, or be self-insured,” which they couldn’t afford. “They left,” Gable mourns. “They had to close the garage to get jobs so they could get insurance.”

Farmers, who are also self-employed, “they’re pretty much taken care of by the wife going to work in the factory.”

Even having workplace insurance, though, doesn’t necessarily insure against financial ruin because of high deductibles and low caps on benefits. Gable will explain to anyone who will ask:

“One company had insurance with a $500 deductible. That’s the same as having no insurance. Then it pays $10,000, and it’s done.” This for workers who were bringing home $100 a week.

“When I first went there, it was $80 a week.”

That was in 1971, when Gable was a new physician. She and her husband, fresh out of seminary, had intended to work in a foreign mission, but instead landed in Konnarock, he as a pastor, she as a medical missionary. It was a sort of homecoming: The Lutheran church had sent her father-in-law there as a minister in 1939.

“There are 400 [post office] box holders in Konnarock,” Gable tells me. “I had 5,000 patients. I saw people from Bristol to Wytheville, from Independence and from Jefferson, North Carolina” and a list of other places, known to few outside the region, which she rattles off at breakneck speed.

Four years ago, she left for Northern Virginia, in her second and finally successful effort to leave behind the all-consuming life of a rural doctor in a high-poverty area.

“I hadn’t been able to go to a museum — to have a day when there was no doctoring on my mind. I had been divorced 10 or 15 years. … My 60th birthday was staring me down.” Then one day, while going through the office mail, “this recruitment letter was there.”

She had thought to leave earlier, after ballooning administrative costs forced her to cut an associate she had taken on for a couple of years.

“There are more than 1,300 different for-profit insurance companies in America,” she notes, thinking back on her desperation. “Even for a missionary doctor, a lot of money comes through the private insurance system. And I was trying not to die with my boots on.”

Gable sent a letter to box holders telling the community that, unless she could get help, the practice would close.

Working with Rep. Rick Boucher, people launched a letter-writing campaign that succeeded in getting her medical mission designated as a nonprofit community health center, eligible for government funding.

In 2002, she essentially donated her practice to Stone Mountain Health Services. “They enabled us to offer veterans services,” she explained in an e-mail following up on our phone conversation, “and they put mental health in place.” The corporation took over administering the practice, which it does still, and she started drawing a salary.

Still, Gable says, “I was about on my last leg in Konnarock.”

Now she works in Northern Virginia, where she is the recently promoted medical director of Greenspring Village, a 2,000-person retirement community with a 200-bed nursing home. The community has a medical staff of six doctors, three nurse practitioners, a podiatrist and a mental health counselor. She loves it, loves her new life.

At age 60, “I came to practice earning some money,” she says jokingly. “I still work 12 to 14 hours a day, but I’m not on call. The doctors I work with have no idea what a hard doctoring job is.” In Konnarock, “I was on call all the time — I was on call when I was in labor.”

A good chunk of her heart is still there, though she hasn’t been able to bring herself to return even for a visit. She stays connected by e-mail.

“I hear from people there every day. Sometimes they ask for advice; some are just my friends telling me about households. At least half have had a layoff in their family.”

Despite the hard times, she says, “People don’t even have the picture that this is coming down now: Something is going to happen on health care reform.”

She is at odds with Boucher over what that something should be.

Since the mid-1980s, she has been a member of Physicians for a National Health Program, which advocates a single-payer system. In her new life, she says, “I’m just killing myself for the cause.

“I thought I’d get out of my 24/7 job down there. Now, when I’m not in my garden or at my job, I’m working for health care reform.”

“My ask is: ‘Everybody ask Congressman Boucher to support H.R. 676 — Medicare for All.’ The answer from Boucher,” she says ruefully, “is ‘political feasibility.’”

Which is what he talked to me about in a phone call sandwiched between House votes one recent Friday.

“We have an urgent need to assure every person in this country has affordable access to health care,” Boucher agreed. “Nowhere is the need any greater than in my district,” Virginia’s 9th.

“Janice is interested in the Conyers bill, which outlaws private insurance. That is simply not politically feasible.”

Boucher said he backs President Obama’s call to reform the system by building a broad base of support and working “to the maximum extent possible to build reform on the existing base of insurance we have, private and government.”

Gable would eliminate the private payers to improve efficiency and quality — and fairness.

What she sees as insurance industry propaganda about health care rationing in other countries carries no truck with her.

“We ration care” in this country, she says. “Those who can’t afford it can’t get it.”

She points out that Medicare, a single-payer system, successfully cares for elderly and disabled people while keeping administrative costs to 3 percent. Private, for-profit insurers, she says, have administrative costs of 24 to 30 percent; they spend a lot of money determining who not to insure: people most likely to get sick.

“We need a different kind of rationing — because we can’t have everything — rationing based on best practices.”

“I’ve been very happy with my decision to come up here,” she tells me by phone, but she hasn’t left the Appalachians behind. “I’m going to be a voice for what the people in Konnarock need.”

“I have written on my refrigerator on a sticky Post-It: ‘90,000 federal lobbyists’ in the city I now live in, Washington. I saw it in Washingtonian magazine.

“It’s a reminder of what we’re up against.”

Strother is a member of The Roanoke Times editorial board.

Credit: The Roanoke Times, Va.