Saturday, July 25, 2009

Care for All?

I've been silent on the health care debate because I've been trying to understand what's going on, both in the world and in my own mind.  The process can be intimidating and confusing.  I don't have organized thoughts or answers or certainty on all of the issues, but I've been giving them a lot of thought.

My recent trip to Europe has left me admiring much about French health care, but it's not all roses over there.  Though there have been many news reports extolling the virtues of access to health care in the E.C., and the physician-friendlier malpractice situation, people seem to be forgetting that many European countries pay for that with an enormous tax burden and what would be considered unacceptable physician salaries here.  I still think they have it pretty great over there, but they do pay dearly for it. [Click here for discussions on NPR about the Canadian system.]

At the heart of much of the debate about health care, I think, lies another debate, about whether or not health care is a right.  Fellow-blogger and physician Edwin Leap raises this challenging question:  if it's a right - that is, if we're all entitled to it - shouldn't we all be able to get it for free?  This gave me some pause.  We're supposed to strive for equal opportunity via universal access to free education in U.S. public schools, but that doesn't mean we don't pay our teachers.  People may be entitled to get something for free, but somebody still has to pay for it.

Does this mean we all have a right to an education but not a right to get treatment if we're sick or injured? I had always thought in the back of my mind, "Sure, everyone has the right to get help if they need it."  But I hadn't really challenged myself to consider all the details in depth.

When I've imagined patients who need my help, have I really believed, "They have a right to my attention and care, regardless of their ability to compensate me for my time and work" - which on some level the idealistic bleeding heart in me wants to believe - or is it more accurate for me to say, rather, "They all have an equal right to my attention and care (though not necessarily and equal need for it), regardless of their situation or what brought them here?"  That, at least, I believe to be true.

Like complicated math equations that can be simplified and simplified until you finally get one clear statement that articulates a truth about the world, all these concepts churning about in discussions about health care, or race relations, or political freedoms in other nations like China and Iran, etc., I think,  can be distilled in my mind to a pretty simple idea:  every individual has the RIGHT to have his or her intrinsic dignity as a human being respected AND not violated.  

This means I think people shouldn't be arrested or even threatened with arrest in their own homes simply because they are angry and Black, especially when such a threat of arrest would never even come up in an equivalent situation in a white person's home.  This means I think China, Burma, North Korea, Iran, and a host of other nations should allow for freedom of opinion, of religion, of speech, and of the press.  This means I consider child abuse and rape among the most heinous of human behaviors.

But what else can that distillation tell us about our rights?  Do we all have a right to eat and have shelter?  If so, should farmers and builders be providing food and housing without pay?  I certainly don't believe that.  Or, are food and shelter just basic needs - not to be confused with inalienable rights?

This is the question I've been pondering.  Does something being a basic need mean it counts as a basic right?  And if something should be available universally, does that necessarily mean it belongs to everyone by right?

I think people should be able to see a doctor, get care at a hospital, or receive treatments for acute and chronic illnesses and trauma regardless of their employment status.  I simply think people who need help should be given help, just as I believe people who need schooling should be taught.  This doesn't mean I think teachers, doctors, or nurses shouldn't be paid. I'd also want to avoid a tiered health care system in which rich people can get deluxe health care and less privileged people can't - but that's a pipe dream; people who can pay for more stuff can get more stuff.  Somehow I just think it's more unjust when that applies to care for human lives than when it's a relatively materialistic good like a house or car.

So this brings me back to this question: if there's a man in front of me who will die unless I intubate him, does he have a right to get life-saving care from me?  I certainly feel he's entitled to get my help - by virtue of my duty as a physician and fellow-human being if not by right.  I believe if there's any implied request for my help as a physician, I have a responsibility to provide it.  Is that the same as this patient having a right to get it?  I honestly don't know. Perhaps that's a question best left to philosophers with bigger brains than mine.  


Resident Anesthesiologist Guy (RAG) said...

Certainly agree that people have a "need" for healthcare access. I do not believe it is in inherent "right" inasmuch as education, freedoms for religion, speech, etc. are rights. I completely oppose the current attempt towards creating a public option (as I think it will inevitably destroy productive competition, provide worsening care and costs, and burden our society more than Medicare already does), but I do think something must be done. We've seen enough, at least I feel, to know that we cannot continue down this same path. Yet the one being hurried through, despite concerns raised amongst both parties, is clearly not the correct method to correct these issues.

Lawyerdude said...

The public option being proposed, as I understand it, is designed to bring costs DOWN by INCREASING competition. Just on prescription meds, for example, the effect would be immediately salutary b/c of the huge negotiating position created by the public program (see, e.g. Walmart prescriptions). This is precisely why private insurers and pharmaceutical companies are screaming bloody murder.

Andrew C said...

Rights do not exist to provide for people. Our constitutional and human rights require only one thing - that other people leave us alone in certain ways. They are not allowed to infringe on our freedom of speech - that doesn't mean they have to pay for my book to be published, they just can't stop me from publishing it if I so desire!

I am not violating the rights of my neighbor if I refuse to pay for his kidney transplant. It would be very good of me to pay for it if I could, but he does not have a right to my time or my money. If he takes my time and money by force, either directly or via the government, it is not an enhancement of his rights, but a violation of my right to be secure in my possessions.

Jo said...

I'm coming at this from the other side of the Atlantic - in the UK, we have the NHS, providing free/subsidised health care for everyone, and, whilst it does creak round the edges, I feel that it is a system which we can be proud of.

Everyone has the right to access medical care, whether that is their GP, a hospital, or a specialist (though obviously, with the specialist, you need to be referred by a GP to try to cut down on abuses of the system).

Yes, it isn't perfect. Yes, you have headlines where people are being denied drugs because someone has had to be a bean counter decided that it is too expensive. Yes, you have abuses of the system (as shown definitely by the levels of panic over the H1N1 outbreak!). But overall, it works. I have had two major health panics, which have involved a number of hospital tests. At no time have I had to worry about whether I could pay for them.

One of my friends has just married an American lady; they have moved to the UK, not because they particularly wanted to live here (there were pros and cons on each side), but because six months before the wedding, she was diagnosed with MS. When talking about it, she said that even though she had a relatively good health care plan, the value that they would pay out on the medication that will keep her out of a wheelchair would not last her three months. In the UK, she gets this medication at a subsidised rate; this means that she stays as a functioning member of society, working and paying her taxes, and her husband also stays in work, paying taxes, rather than having to quit work to look after her. It also saves the NHS money in the hospital visits / nursing care that she won't have to have.

Lawyerdude said...

Jo - I'm glad to hear of your positive experience in the UK. Bean counters and approval of referrals are a fact of life, whether its private or public health care, so that criticism of the public option does not resonate with me. In the US legions of lawsuits have documented how private insurers have systematically denied and rescinded coverage for their insureds after they get sick, presumably to cut costs and make money (which is their mission, after all). Given the choice, I would rather have a government agency (whose mission is to cover basic health care) monitoring my health care use rather than a private company whose corporate mission is to cover as little care as they can get away with.

ZMD said...

I never did understand why the wealthy should not get "deluxe" healthcare if they can afford it. We don't begrudge them if they eat foie gras and filet mignon while the rest of us have peanut butter and jelly. When they drive Mercedes while we drive Hondas we don't say that's elitist. So why shouldn't they be able to pay for upgraded concierge medicine if than can afford it? Everybody still gets the same basic level of care (malpractice lawyers will see to that)but the rich just gets to have nicer ammenities.

Transor Z said...

First, a reminder that here in the U.S. we are governed by both state constitutions and the U.S. Constitution. Their definitions of what are "rights' can differ dramatically, as with the Massachusetts constitution's powerful equal protection provision that results in full, equal marriage rights for homosexual couples. So don't overlook your state constitutions!

Similarly, when we discuss "rights," it's important to identify the sources of our claimed rights. The Universal Declaration of Human Rights is very different from the U.S. Constitution.

For example:

Article 22.

* Everyone, as a member of society, has the right to social security and is entitled to realization, through national effort and international co-operation and in accordance with the organization and resources of each State, of the economic, social and cultural rights indispensable for his dignity and the free development of his personality.


Article 25.

* (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
* (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

I agree with earlier posters who (I believe) accurately describe American founding notions of fundamental rights as involving freedom from constraints rather than economic entitlements. In the U.S. tradition, education is not a right (it is Art. 26 of the Univ. Declaration). Once provided by a government actor in the U.S., however, the economic benefit must be conferred equally.

With respect to cost, I think most Americans would be shocked to learn that, among highly developed nations, only Switzerland spends a higher percentage of total government spending on health care than we do. The major difference is that the Swiss and other nationalized health care countries contain costs to the point that they achieve a much higher level of coverage.

Ultimately, I believe that T. hit the nail on the head with cost containment -- which we all understand to mean reduced profits for Pharma and lower salaries for physicians. HMOs would probably wither, assuming the proposed plan successfully competes with and ultimately supplants the existing non-system. But even in Europe people purchase supplemental coverage.

If you're watching what is happening in the larger economy right now, we're seeing a reversion to thriftier spending/savings habits. As Americans work to get out from under unprecedented levels of household debt, consumption can only continue to remain low for the next few years. In a sense, Americans are behaving more like the rest of the world from a consumption standpoint.

So a time when we are seeing lower wages and, we can only hope, more focus on quality of life issues, seem to me like as good a time as any for doctors to join the crowd. Relative social status doesn't change when the tide drops for everyone. But compensation will drop for doctors -- proportionately. It has to.

WWWebb said...

Anesthesioboist writes: This means I think people shouldn't be arrested or even threatened with arrest in their own homes simply because they are angry and Black, especially when such a threat of arrest would never even come up in an equivalent situation in a white person's home.

I'm calling BS on this one. You've never watched the television show "Cops"?

If you mouth off to police officers or behave in a noncompliant manner, you'll probably earn a ride in a black and white.

Pigmentation or lack thereof notwithstanding.

WWWebb said...

While we're at it, let's differentiate between the UN Declaration and the Constitution in terms of where they source the rights contained therein:

The UN Declaration GRANTS rights (none of which are absolute or unalienable- see Articles 29 and 30, which, in effect put asterisks next to all previous sections).

The US Constitution ENUMERATES rights with which we are endowed by our Creator. It doesn't GRANT us anything.

T. said...

WWWebb - I don't watch much T.V., so I'm uninformed about the show "Cops." We'll have to agree to disagree on the arrest issue.

I am by no means well-versed in philosophical matters, but I think I probably lean toward a Lockean view of natural rights, so whoever "grants" or "enumerates" them is really irrelevant. I'm more interested in understanding what rights each individual should have regardless of any governmental, political, or historical interpretation, legislation, or constitutions.

That, admittedly, is a personal interest, and as such is tangential to the salient issue here: whether and how to implement universal health coverage. I think the answer to "whether" is emphatically YES; "how" is another, more complex matter. No one system is perfect, and the best offerings of systems implemented elsewhere may be difficult or impossible to utilize here. I think the speaker who described the virtues of the Canadian system (for all its flaws) summarized it well (I think I linked to it in the post) - people shouldn't have to WORRY about being able to get help when they need it in any so-called "advanced" or "wealthy" nation/society.

WWWebb said...

I certainly agree that our system isn't perfect, but anybody who expects the government to make health care either more efficient or more cost-effective-- I'll be charitable here and avoid phrases which would imply that the DSM-IV should be referenced-- hasn't had much real-world experience with government.

I came to your blog via Bongi, who spoke highly of you in his blog. I believe his opinion to be correct.

T. said...

Thank you, WWWebb. I'm very glad to have you and your perspective here. I'll agree the very thought of almost anything "government-run" makes one want to groan...The question is, how does health care delivery work where it seems to be working well, and what makes it work?

Others have pointed to examples in Western Europe (Switzerland, the Netherlands, Germany, France) - but it seems to me with smaller geographical areas and populations, universalizing health care might be easier in those places than it would/will be in the U.S.

It's for issues like these that I wish I were better-versed in economics, sociology, policy, etc. - admittedly not my strengths.

gcs15 said...

"But compensation will drop for doctors -- proportionately. It has to."

This statement boils down to simple class warfare.

Why can't people seem to understand that the problem is not doctors' salaries? That's a miniscule percentage of health care costs. How much do people think physicians make, anyway?

If compensation does drop for doctors, quality of care will drop proportionately. Good physicians will leave medicine, because the sacrifices we make will no longer be sustainable. Bright, dedicated students will choose other, more financially rewarding professions. And guess what? The cost of health care won't change.

We should not be ashamed of earning money for the work we do. Others (politicians especially) should be ashamed of trying to take it from us.

Andrew C., thanks for summing it up so succinctly. Right on target! Little else need be said.

T. said...

I agree, a pediatrician making 85- or 90-grand a year is hardly the MAIN problem when you ALSO have drug or technology companies making hospitals pay ten times more than it costs them to make a product, or emergency room visits in lieu of preventive care (probably not a huge factor, admittedly), or chronic-hospitalization costs for the very ill and aging, or high-tech interventions for the acutely ill (much more frequently used here than in other industrialized nations - yet THEIR life expectancy is HIGHER. HMMM).

Other things that drive up costs, I think, are the need for defensive medicine - lots of tests, lots of overtreatment; consumerism - one reason I abhor the "patient as customer" concept and actually reject the notion; and inefficiencies in the system (read: PAPERWORK).

But I think the simplest answer to why health care costs more here is because, from what I've read - and this might sound funny - the prices are higher. Yes, it costs more because it COSTS MORE. The same goods and services cost much more HERE than in other countries. Or so I've observed in my travels, and heard, and read.

Transor Z said...


My comment referred to wage deflation and the vaporization of several trillion dollars in US GDP through the bursting of the credit/real estate bubble. Physician salaries will need to decrease in proportion to across-the-board declines in salaries in real terms as the economy settles into a sustainable level.

For a data-driven discussion of health care costs and spending, I recommend Paul Ginsburg's "High and Rising Health Care Costs: Demystifying U.S. health care spending," available for download at

Hospital care and physician and clinical services are by far the two largest components of personal
health spending, accounting for 31 percent and 21 percent, respectively, in 2006. Prescription drugs account for only 10 percent of overall spending, although that is 40 percent higher than its share in 1970. Growth rates of the distinct components differ by time period, with the rank order often changing from decade to decade, but each of these three has had higher rates
of growth than the remainder of health spending.

gcs15 said...

Strange, then, that physician "reimbursements" (in other words, how much we get paid for each office visit or procedure we do) have gone down steadily over the years. (I would refer you to the CPT coding system for data on this.)

Also, I wonder if "physician and CLINICAL services" includes things like imaging and labwork, things that physicians DON'T GET PAID FOR. Let's separate those components out, reanalyze the percentages, and then calculate how much would be saved on imaging and labwork etc. if tort reform were enacted...

Remember, despite popular misconception, physicians get paid for the office visit, not the tests they order. When I order an MRI, I don't make any money from the procedure. When I write a prescription, I don't make any money from that.

I get paid less for doing a carotid endarterectomy (and managing the patient for 90 days postop) than a painter gets paid for painting my kitchen. And the solution is to pay me LESS?!?!

Let's talk about things like insurance and tort reform that would make a real difference, not about punishing evil rich doctors.