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With overhauling healthcare back on the national agenda, politicians are talking about how to improve the system for the first time since 1991. In the second story in our weekly series, NPR's Joanne Silberner finds out how medicine has changed for one doctor since the Clinton effort failed.
JOANNE SILBERNER: Dr. Rebecca Jaffe has a huge black-and-white framed photo hanging behind her desk in her office in Wilmington, Delaware.
REBECCA JAFFE: That's me on my third birthday sitting on my grandmother's step with my junior doctor kit.
SILBERNER: The little girl in the picture is very proud. When she grew up, she wanted to be just like the doctor who took care of her family.
JAFFE: He saw something different every day because he was a family doctor.
SILBERNER: What Jaffe didn't know when she was a little girl was that her life would be very different from her family doctor's. Between the early 1990s and now, Rebecca Jaffe has been struggling to spend time with her patients while disputes with insurance companies demand more and more of her attention.
JAFFE: The truth of the matter is insurance hopes to keep people well until they're 65 and on Medicare, and then it's not their problem.
SILBERNER: She says I have to fight to get my patients the care they need.
JAFFE: Unidentified Woman: Oh please.
JAFFE: That's okay. I got him.
SILBERNER: Six-month-old Gabriel Persing(ph) grabs the protective paper on the exam table in his tiny fists and holds on for dear life.
JAFFE: Unidentified Woman #2: You're a tough guy. Oh, buddy. It's okay.
SILBERNER: Jaffe says insurance companies watch costs aggressively. And on two occasions insurers told her they'd pay less for an immunization than it would cost her to even buy the vaccine.
JAFFE: They said that we should make up the costs somewhere else and with volume. And I just felt that that was so wrong.
SILBERNER: Because, she says, good medical care takes time.
JAFFE: I could make a lot more money if I saw five or ten more patients in the day. But at the end of the day, would I feel good that I've given them the best care that they could have had? Maybe not.
SILBERNER: These days it feels like every patient with a health problem also has an insurance problem. Jaffe tells about one, the daughter of an elderly woman came in to say her mom's Medicare drug coverage wouldn't pay for prescriptions anymore. She'd used up the first $2,250 of coverage Medicare recipients get each year.
JAFFE: This is a woman who's had multiple strokes and she was on four anti- hypertensive drugs, plus blood-thinning drugs.
SILBERNER: Jaffe said the daughter told me she couldn't pay for the mother's drugs herself.
JAFFE: Every time we saw a drug rep who carried one of her drugs, we asked them if they could supply us with free samples. And we pared down some of the medications she was taking, although it made me extremely nervous. Because her daughter said unless you can give me the additional $400-plus a month, I don't know how to prioritize this.
SILBERNER: Sometimes, Jaffe says, despite her best efforts, she can't help. She has one patient with no health insurance and not much income. His father, two uncles and a cousin all had colon cancer. She was worried. The patient needed a colonoscopy so that any early cancer in him could be removed.
JAFFE: I called a few of the gastroenterologists, all of whom were willing to do the colonoscopy for free. Unfortunately, there's a facility fee.
SILBERNER: She says I spent hours on the phone researching places for free care. That went on for months.
JAFFE: And that is the crime of what's going on in America today. I can't believe he didn't get his colonoscopy a year ago.
SILBERNER: She says she should be practicing medicine, not searching for ways to pay for it.
JAFFE: Somebody's got to do it. Who else is going to advocate for those people?
SILBERNER: And once all her patients have left for the day, mounds of paperwork stare her in the face.
JAFFE: I'm stuck, you know, being a secretary more than being a doctor sometimes.
SILBERNER: Two hours at the end of most days that she could be using for patients. Instead, she's filling out forms, sending in requests to insurers.
SILBERNER: On top of that, she's making 7 percent less this year than last. Compared to specialists, her salary is already low, hovering around $140,000.
JAFFE: Maybe I should have done something different, but I love what I do. It's just sad that the way the system is set up the compensation is skewed.
SILBERNER: But it's her patients' finances that she worries about. As time goes on, their out-of-pocket costs are going up and more and more of them are losing insurance entirely.
JAFFE: It's a broken system for a part of the population. It's a bumpy system for others.
SILBERNER: Joanne Silberner, NPR News.
MONTAGNE: You can hear the first story in our series, a look at how the issue of healthcare is once again in the political spotlight, at npr.org.