Repost: Medical Care, right or privilege?

I am having trouble staying silent on the current loud and rowdy health reform argument (I haven’t really seen much debate), then again, I haven’t been silent.  Here is a repost of my position, first published in February 2008, layed out as clearly as I can make it.

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     For over 20 years our country and its undying commitment to capitalism have tried desperately to slow mushrooming healthcare costs, and failed miserably. HMOs, Capitation, things that business was confident would succeed where those fiscally incompetent doctors failed, fell flat. Patients, it seems, did not tolerate their health and well-being treated as a business. I suppose business was part of the problem. After during WWII, with wages fixes and worker shortage, jobs starting sweetening benefits with healthcare and insurance to compete. It turns out patients and workers really, really like this system. It removes us from feeling any of the pain in our wallets with doctor visits and poor health.

Speaking in strictly capitalist, business terms customers were going to receive services from physicians, while a third party, insurance companies and businesses footed the bill. This removes some of the natural checks on inflation of cost. The patient and the doctor can now gang up on the third party payer, making control of spending difficult. So as an economist, obviously we just need to restore the marketplace, right?

It really depends on how one envisions healthcare. I can’t see going to the doctor or hospital the same as shopping for a new SUV, or getting cable TV. Our health is a fundamentally different thing, central to our quality of life, our independence, even the pursuit of happiness. Is it something people deserve or something we buy, dependent on our resources and wealth?

Without question it is dependent on our wealth to some extent, because it is creating a very real drag on our economy. Businesses have been weighed down with the cost of healthcare to the point where even the most heartless capitalist is demanding that the government do something to fix this mess. We spend more on healthcare by far than any other nation in the world. In spite of this, we have huge inequities in care with a mushrooming population of “working poor.”

These are people who have jobs and contribute to society, eliminating their eligibility for medicaid, but don’t have access or resources to get health insurance, so they go without. These people do take themselves out of the equation. The price checks work, as they stop seeing the doctor, that is until their uncared for hypertension, diabetes, cancer, lands them straight in the hospital desperately ill, devouring resources. But hey, a recent study actually showed this saves us money. We should just let them shorten their lifespan right?

You could even go so far as to say they deserve it for not taking care of themselves. If they just ate right they wouldn’t get hypertension or diabetes, right? Problem is fat, sugar, processed food are very cheap. Fresh fruit, vegetables, unprocessed grains are not so cheap and take time to prepare, time that could be spent working away at your minimum wage job to make ends meet. No, I am afraid blaming the poor has become an American pastime, one I am deeply ashamed of.

I have witnessed it firsthand. In medical school, our catholic hospital often received “patient dumps” from another large private hospital. These were medicaid patients, the cost of their care being eaten by the hospital. Medicaid pays substantially less than the actual cost of healthcare with the thought being that Hospitals and Doctors can take the hit as doing their share of charity work. This being the real world, the cost is passed on to everyone else through inflated costs to cover losses caring for the poor. These losses would be very manageable if the poor were evenly distributed among us, and everyone took in their share. Alas, the poor are concentrated in the inner cities, the victims of family flight to the suburbs, or in rural areas where the resources are scarce. We now have laws outlawing patient dumping and ERs everywhere are becoming the primary health care clinic for the poor. ER physicians are frustrated, burnt out and cynical. Many of them blog about it. Many of them grow contemptuous of those they care for. It is sad really.

The president recently stated that we actually have universal health care in this country. He was referring to our “safety net”, government and community hospitals. In fact all hospitals are now required by law to take care of everyone who walks through their doors, regardless of ability to pay.

I have spent a good portion of my training in county and inner city hospitals and I have seen our safety net in action. I have watched as a hospital has closed, causing an overflow of the poor to other hospitals. When the poor arrive in too large of numbers, the old patients get spooked. They equate care for the poor with substandard care. They leave and take their insurance with them. The end result is that, indeed, care for the poor becomes substandard. Morale in these hospitals is exceedingly low. They go bankrupt, they cut staff and wages to make ends meet, they outsource, then they die. All the while, patients with money cause the suburban hospitals to thrive, explode, and expand. This is what it means to make healthcare a commodity. This will destroy our “safety net.” This is a crisis.

A main argument I have seen on other blogs against a single payer system is that people will expect more, waste more and everything will cost more. They state that patients won’t tolerate the rationing of healthcare that a single payer system will require. Governments won’t control the spending because it is politically harmful. I agree. I can tell you right now, patients don’t tolerate rationing. We have a tiered system with quality going to the highest bidder. This is capitalism, welcome to America, right?

I just can’t embrace it. My stomach has turned watching the market in action as hospitals are destroyed and the face of the poor ground upon. The resources available to medicine are not unlimited. We do have to face this. Personally I believe a single payer system would at least be a huge improvement over the fractured system we have now. You could tax business what they are paying for healthcare right now, eliminate all the duplication of beauracracy in insurance companies and with the money you save, put it toward real quality that benefits everyone, all without raising costs, which you could fix with inflation adjustments to force economic responsibility. Since we spend twice as much on healthcare as any other nation, we would have the best system in the world instead of the most wasteful.

Realistically you would still have two tiers. The Uber rich, I am sure, would feel they wanted something better and would pay out of pocket to doctors that would only be too happy to oblige. If they pay taxes and foot the entire bill, I suppose it is only fair. They would be a definite minority. The important thing is that healthcare would become a resource that we share.

There is a certain basic concept that we are beginning to forget in our society, the concept of common wealth. Way back in the days of print media, communities would pool their resources to build a collection of books we call a library. This was because information and education was felt to be mutually beneficial if shared. The poor can only benefit from learning. We all can gain more as a group, enriching the whole, than any of us can individually. This is a way the group can protect resources from individuals who would devour or horde them. It turns out that together we have much more than any of us could ever hope to acquire individually. This is the thinking behind public museums, national parks. These are something different than commodities. They are actual sources of well being. This is our true wealth, and it is shared.

The common wealth of America are habitats, ecosystems, languages, cultures, science, technology, schools, social and political systems, democracy. These are things often so basic we sometimes forget how much we have. They are things we all value together and are well worth fighting for. So is medicine a right, or a commodity dependant on resources and wealth? My answer has to be an unqualified yes, it’s both.

I believe, sincerely in the depths of my soul, our commonwealth has to include medicine. We need to protect it, not exploit it. I doubt any of us could calculate what exactly any of these things would cost on the open market. I think it is safe to say that taken together our common wealth’s value exceeds all we could ever own privately.

This is why collectively, we need to move to protect healthcare and medicine and distribute it among ourselves equally. Yes this means placing some trust in the government, which after all represents all of us. I am just enough of a hopeless optimist to suggest this is something we must fight for. In the end, I have to come down believing health care is a right, inextricably tied with life, liberty, and the pursuit of happiness. I leave you with this closing thought about what I believe society should and can be.

“We need to speak up, to say boldly why we fight for good schools, why we build houses for the homeless, why we protect open space, why we look after the ailing and the elderly, why we pay taxes without grumbling, why we honor government as a force for public good. In a society obsessed with competition, we need to say why we practice cooperation. In a culture addicted to instant gratification, we need to champion long-term healing and the welfare of coming generations.”

–Scott Russell Sanders

Arguing your very right to exist.

Harriet McBryde Johnson 1957-2008

     Last December 24th, in the New York Times, Dr. Peter Singer eulogized one Harriet McBryde Johnson.  This was a tribute to their 2003 head to head meeting, in which they sat on opposite sides and engaged in the single most fascinating debate on human rights that I have ever read.

Points of Interest, #33

     I welcome one and all again to my roundup of all that is well with my surfing the internet for hidden treasure of knowledge relating to all things mind, soul, and body.  This week I have great posts on death, death, and death.  Also parasitic stalkers, forbidden fruit, and Heavy Metal, and smell receptor farming to name just a few.  So dig in and enjoy the very best I could find-

Those People

    As the presidential debates get revved up, I have been scrutinizing their health care plans.  Both candidates rightly insist that something must be done to cover the ballooning and exploding population of uninsured in this country.  For both, the solution will likely include a hit to the pocketbook of Joe Public, whether through taxes, or through private insurance companies that we are required to purchase coverage from.  This has the standard libertarian masses quite upset.  One thing I am hearing more and more about in the argument against universal Health care coverage is “those people.”

Points of Interest #22

There just seems to be something about July.  Everything at the hospital is new and enthusiasm is bursting.  It has made for a busy week in trying to keep up with the very best the internet has to offer.  I have expanded my usual offerings and still have to great posts I’ve left out.  If any of you are real die hard fans, subscribe to the nuggets from all over feed on the sidebar.  For those who just need a weekly fix of the world wide web’s offerings, I present the best I’ve seen-

Name and blame

The always fun topic of autism and vaccines has been in the news again.  Truth is, it never leaves, but this time the whole movement has found new life and hope in the brave, new world of mitochondrial disorders.  It all started when the first ever vaccines caused my child to develop autism case was won in court a few months ago by one of my fellow child neurologists.  Now, with one case in the law books, a second has arrived. I thought I might attempt a look at the issues this brings up.

I am now breaking a vow of silence and entering dangerous territory, the swirling vortex of controversy that is Autism and vaccination.  This is a difficult path for my conflict avoidant self to tread.  The amount of blog space devoted to this subject is long, the tone is invariably impassioned and the feelings involved are raw.  In a way, this is more interesting to me than the question of whether vaccines cause Autism itself.  Why is this such a lightning rod of an issue?

Because they are babies!!!

 

    The answers are actually rather complex, but the biggest factor is dealing with children, whom we subject to multiple needles full of mysteriously weakened viruses and various unknown and frightening substances at regular intervals in our weakest and most vulnerable population.  This undoubtedly requires a great deal of faith and trust in the medical field. I know that we doctors do not always behave in a manner completely worthy of this trust.  The parent child relationship is intense.  Our desires to want the best for them are very real.  There is a very real impulse to take the frustration that comes along when all is not well with the child and direct it at the physician.  I know, because I walk the tightrope associated with this in dealing with the parents of sick children every day.  My hope is that I might allay a fear or two without appearing to be insulting the impassioned opposition.  I have a hard time faulting parents for caring too much.

Points of Interest #19

And now, I present, coming in the midst of actual downtime, rest, relaxation, the bountious fruit of my idle surfing, especially for you the reader– My special vacation edition of the best posts-

Attack of the Mad Scientists?

I recently had the opportunity to listen to a rather provocative podcast at All in the Mind about cognitive enhancing drugs.  Specifically they discuss Modafinil, a drug used to treat Narcolepsy, a disease in which sleep comes suddenly and often, to help them with excessive daytime sleepiness.  I was startled to learn that many in the neuroscience community are using this drug, openly, and sharing it with others in order to work longer hours, get more done, focus more, and think more.  This blew we away.