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Framing the Health Care Debate

I posted about my Twilight Zone experience of navigating access to military health care for my daughter’s knee injury. My point in the post was not to lambast the military health care system. Rather, my intention was to point out that a government run system is not the panacea for our ailing health care system. That our system is ailing cannot be denied. Health care providers are not happy. Patients are not happy. And nobody’s pocketbook is happy.

In 2002 I spent a year in an academic setting studying the American health care industry. It was a very informative year. I had been practicing medicine for over fifteen years at that point and I had witnessed first hand the evolution from standard fee-for-service medicine to the managed care rationing of services. This year of study gave me a much broader picture of the American health care system.

Let me begin by saying there is no universal definition of health care. Everyone is shouting for universal health care but I haven’t heard anyone define what that means. There are true health care needs and then there are health care wants. Defining what is a need and what is a want is fraught with political perils. Childhood immunizations are a need. Basic prenatal care is a need. However, does every pregnancy need an ultrasound? Probably not. That is sometimes a want.

Every disease and affliction has a lobbying group demanding government support for their specific ailment. It is the role of the government to provide for the common good of the governed. However, not all health care is for the common good. The challenge is to adhere to the principles of natural law and the dignity of each human being and meet the true health care needs. There also must be an element of personal responsibility in providing for health care. Lack of insurance coverage does not always mean lack of access. This is a very small-scale example of what I mean: I had a mother bring her feverish child into the emergency room. After diagnosing her illness I was able to give her samples of an antibiotic and we had given the child a dose of acetaminophen for the fever in the ER. The mother was furious with us because we had no acetaminophen to give her to take home. She complained bitterly that she had no money to buy acetaminophen for her child. My nurse noted that for the cost of the cigarettes in the woman’s purse she could buy acetaminophen. This woman made a personal choice to buy cigarettes for herself instead of medicine for her child yet she was angry that someone else wasn’t taking care of her child’s needs.

Let me offer a very rough analogy. Auto insurance offers coverage for damage incurred in an accident. It does not cover routine maintenance. Therefore, automobile owners must budget for oil changes, tires, and other maintenance. Health insurance offers a wide variety of coverage options. Depending on the product you buy, some medical options will be covered and some will not be covered. Somehow many have gotten the idea that we should never have out of pocket health expenses. The truth is the cost of health care will always come out of our pockets. It will either be a direct payment to the provider, a tax payment to the government or a premium payment to the insurance company. Do you really think a government bureaucracy will provide a higher quality service, more efficiently and at a lower cost than a private enterprise?

I do believe that it is objectively possible but politically perilous to define what is basic health care. Governments have a responsibility to ensure each of their constituents receives this basic health care. I also know that if basic health care is accurately defined based on scientific evidence, there will be great wailing and gnashing of teeth as people find out their favorite medical option is not included in a taxpayer funded medical plan. A great deal of the health care Americans receive is actually elective care, and not medically necessary care. Taxpayer funding should only go to necessary care. I also believe every American should then feel free to purchase whatever bells, whistles, and frills he wants for his health care. Whether it is purchased by direct payment to the provider or by indirect payments to private insurance doesn’t really matter.

This approach means that not every American will receive the same level of medical care. But it does mean that every American is entitled to and will receive some basic level of care. Our current system has by default set the safety net at life-threatening acute conditions. Anyone with a gunshot wound, blunt force trauma, or cardiovascular collapse will be whisked to the local emergency room and medically stabilized without regard for payment ability. What is not available and should be available to every American is primary care and prevention for illnesses like hypertension and diabetes. When it comes to primary care medicine we have a system of “haves” and “have-not’s”. We need to move to a system of “haves” and “have-more’s”. This is very hard to sell, politically. However, to demand uniformity in health care delivery is to ensure mediocrity for all and excellence for none.

There is much more to say on this topic and I will be posting more in the near future. Consider this post as the initial foundation for a more detailed discussion later.


jawats said…
Dear CMimDC / AM,

When you discuss these matters, there are a number of issues I'd like your opinion on, if you would be willing. They are:

1. The United States has separate state and federal governments - to which belongs the responsibility of health care, and why?

2. How do the requirements of subdiarity fit in? See it is an injustice and at the same time a grave evil and disturbance of right order to assign to a greater and higher association what lesser and subordinate organizations can do - Quadragesimo anno (See also Centisimus annus - JPII).

3. Should there be a universal system, or one dedicated to helping those that cannot afford health care and / or cannot work due to no fault of their own?


Milehimama said…
My sister just did a series called "Right to Healthcare" on her blog last week, that touches on many of the same points.

Here's her post on "One Definition" of healthcare:

Thought you might be interested.
David Jackson said…
Having worked in the health insurance industry I can honestly say that as long as a for profit entity is determining the efficacy and cost effectiveness of a doctor's treatment plan, the health care system will continue its decline.

On the other hand, having watched my brother-in-law struggle with the VA Medical system, it doesn't appear government has the right answer either.

IMHO, non-profit entities (insurance companies and providers) are likely going to the be the best avenue for health care with any sense of the cardinal virtue of justice, even if they never achieve having the latest and greatest treatment options.
Anonymous said…
Ick - the term universal health care makes me shutter. The reason - American's first hand experience with other country's health care.

ie. I have a friend, working in Canada, who after falling on the ice and being unconscience/bleeding for an hour, was finally found. An ambulance came and took him to the hospital. There he had to wait in a long line (whoosy & standing,) to check in. Then he had to STAND in another line to see the doctor, another to get an x-ray. At the end of the night, they put him in a taxi, and gave the driver instructions to have the HOTEL STAFF wake him up every 3 hours. He was in bad shape when the company doctors found him the next day - incoherant and alone.

Not quite the healthcare we get here in the states.

Or how about the stories of people getting cavities filled without anestesia in Switzerland? Or how women must labor at home, and only go to the hospital last minute in some place in Europe?

universal health care =
minimum care = a step backwards for America
Jim said…
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Jim said…
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Jim said…
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Jim said…
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Rosemary Bogdan said…
Denise, really interesting post. Thanks for sharing your insight.
Ginkgo100 said…
Thanks for your comment on my blog. I quoted you on my most recent health care post. I'm really looking forward to reading more of your insights!
RAnn said…
I look forward to reading your other posts on the topic. I wrote my two cents worth here:

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