Tuesday, September 04, 2007

Worthiness, Socialized Medicine, and Individual Responsibility

My last post examined the questions: Who is worthy of having adequate health insurance and high-value (safe, cost-effective) care; what makes them deserving? And who, on the other hand, is unworthy; what makes them undeserving? I linked to this post on another forum, which led to an interesting conversation about personal responsibility. Following are excerpts from that conversation. I welcome your comments.

One person commented:

Everyone deserves unobstructed medical attention for illness and injury; curable, chronic, and/or terminal. In that I see an absolute fulfillment of the constitutional mandate to see to the 'general welfare'. One step beyond that is preventive care, more opinionated and intellectually based; but I none the less would consider that the 'general welfare'. Every other service for everyone associated as medical service should remain privately financed and marketed (like child bearing and voluntary procedures).

One critical issue within that position is how to deal with self induced health impairments. This health class should have a name, definition, and social remedy. Let's call it IHIs. It's tough because it's smoking, poor diet, drug addiction, STDs, poor dental care, high risk sports, etc. I'm thinking IHI classification puts an individual into a special insurance category requiring addition premium or mandatory savings both during and for some time after such circumstances.

I replied:

Yes, dealing with the kind of self induced health impairments (IHIs) is a thorny issue.

A logical case can be made for having those with the financial means pay out of pocket for at least a portion of treating health problems clearly determined to be voluntarily induced. That is, delivering care to people with adequate maturity, knowledge, intelligence and rationality, but who make a conscious decision to engage in high-risk behaviors and suffer the consequences, would cost them more, so they are held accountable for their actions.

Unfortunately, many (most?) of these people are either (a) immature (e.g., teenagers enticed by tobacco and alcohol marketing, as well as peer pressure, and then get hooked); (b) ignorant, confused or unintelligent (they don't fully realize or understand the risks of eating too many greasy french fries and failing to exercise regularly, or they have trouble self-managing a chronic condition requiring a complex medication regimen and lifestyle changes); (c) irrational (e.g., they deceive themselves into believing they can stop taking drugs, or they are self-destructive due to a psychological problem); or (d) they lack the funds and support needed to live a more healthy lifestyle (all their time is taken working day and night at minimal-wage jobs, or they lack affordable transportation, to visit the dentist every 6 months, or they can't afford fresh fruits, vegetables and lean meats when pasta is a fraction of the cost). Or, they just might be unlucky (e.g., the got an STD because the rubber broke).

In other words, this is a complex issue and a great deal of thought should go into defining the conditions for the kind of punitive costs you propose.

Also consistent with your suggestion would be a policy of taking punitive action against the manufacturers, distributors, retailers and marketers of unhealthy foods and ineffective medications and supplements. And what about tobacco companies and alcoholic beverage producers who promote their products to college students, and even the promoters of dangerous sports?

It seems to me, therefore, that establishing a reasonable two tier system--one for folks who self-manage their health effectively and another for those who don't--is a daunting task, but one worth examining.

On top of this is the question of whether contraception, abortion, and child bearing should be paid privately.

Nevertheless, the bigger issue in my mind (and discussed in my blog) isn’t about penalizing certain people for poor behavior; instead, it’s about enabling and rewarding the delivery of high-value health and healthcare services. I contend that minimizing waste, inefficiency, and ineffectiveness--while maximizing transparency of quality and cost, along with wellness education and services, and rewarding positive results--would actually save so much money that there would be no need of the kind of two-tier system proposed.

Another person commented:

Providing the kind of general welfare you propose is way beyond what our founding father meant by this or far beyond any logical interpretation. Providing for the general welfare means our legal citizens ability to pursue their lives and work safely, securely, and free of government inference and detailed mandating. It in no way means the government should tax everyone to pay for things that everyone has the freedom to choose. This includes medical care.

Per the Census Bureau's 2005 / 2006 census report:
  • 10,231,000 non-citizens are uninsured (See page 21 of the census report) - the increase from 2005 to 2006 in this area represents 38.3% of the .5% increase in uninsured PEOPLE
  • 17,742,000 uninsured Household earned $50,000 and more in 2006. (See page 21 of the 2006 census report) These People certainly could afford to acquire their own health insurance.
Socialized health care means we taxpayers will be taxed and pay out billions and billions for illegal aliens and citizens who can afford health insurance but "choose" not to. Where will these billions & billions will come from? Much higher taxes or major reductions in other government programs or a combination of both - or simply higher taxes!

I am unwilling, as well as, unable (I am retired and on a rather fixed income) to pay for the healthcare of illegal aliens and those citizens who want me to pay their way!

And last, but not least, please provide valid, relevant, accurate, and complete statistical data which clearly shows those countries who have socialized healthcare provide healthcare of equal or better than is currently provided in the US.

This does not mean major improvements are desperately needed in our present healthcare systems! But these are improvements not a replacement! I will not hold my breath waiting on the healthcare industry to make these needed improvement, because of government regulations and interferences! The politicians are a major part of our healthcare problems, not a solution among them! :-)

I replied

You said: Our government [should not] tax everyone to pay for things that everyone has the freedom to choose. This includes medical care.

While I agree with your premise, I don’t believe it’s about “freedom of choice.” There are many reasons for people not having coverage, including:
  • Health insurance is unaffordable to many, including individuals who are unable to get affordable individual coverage due to cost or pre-existing medical conditions.
  • Many employers do not offer health insurance coverage.
  • People who lose their jobs often lose their health insurance.
  • Some workers are not eligible for health insurance offered by their employer.
  • Workers and individuals do not take-up coverage that is available.
  • People may be poor but not eligible for public coverage, for example, childless adults are generally ineligible regardless of income.
  • Individuals are eligible for public programs, but are not enrolled.
(references: Why are people uninsured #1 and Why are people uninsured #2)

You said: 17,742,000 uninsured Household earned $50,000 and more in 2006. … These People certainly could afford to acquire their own health insurance.

It seems to me that the number of folks who can afford insurance and simply chose not to get it is very small. Take your example of a family earning $50K/yr. In NY, an HMO family plan with steep copays and deductibles and no dental, offered through a small business, cost a family over $11K/year in premiums alone, which increases every year. That’s a sizable expense even for a family earning $50K, on top of out of pocket dental costs, as well as copays and deductibles. I don’t see that many fail to buy insurance because they’re looking for a “free ride.” I say this in light of the fact that the uninsured tend to have worse health and, when they get sick, they have to wait for hours in a emergency room or go to a community clinic safety net facility. This is not a glamorous option.

Another group, btw, are the “underinsured” who purchase coverage and then are shocked to realize that what they have doesn’t come close to paying their medical bills. According to a recent consumer reports study, 24% of Americans have health insurance that barely covers their healthcare needs, not to mentions the 16% with no insurance at all. This leaves a huge number of people unprepared for major medical expenses.

You said: Please provide valid, relevant, accurate, and complete statistical data which clearly shows those countries who have socialized healthcare provide healthcare of equal or better than is currently provided in the US.

I don’t believe such clear-cut data has ever been collected to make the case one way or the other. But there is convincing data that the US lags behind many industrialized countries in delivering primary care, access and quality … while at the same time costing much more than other countries. See, for example, The Commonwealth Fund (Sep 20, 2006). New National Scorecard: U.S. Health Care System Gets Poor Scores on Quality, Access, Efficiency, and Equity. Available at this link.

You may also want to visit this link to a page on our WellnessWiki for more facts and figures about the healthcare crisis.

As far as not holding your breath waiting on the healthcare industry to make needed improvement due to government regulations and interferences, I don't blame you! It will take strong leadership, new mind-sets, innovative policies, and consumer pressure to change the system in the kind of profound ways I propose.

And what about dealing with undocumented workers (illegal immigrants) who are hired by American employers to do back-breaking work at below minimum wage? I understand when our citizens complain about the cost of giving them free healthcare. But consider the alternatives: We can let them die in the streets without any aid and pray they don’t pass contagious disease due to lack of treatment, waste huge sums of money building walls around our country in the na├»ve hope that we can keep them from crossing our borders, etc. And we could punish employers who hire them to do back-breaking menial labor few of our citizens would do, but that wouldn’t help much since we need them and they need us for work to feed their families.

Alternately--and I realize this is controversial--we can adopt a national policy that makes the U.S.A. the world center for promoting health !

Why? Well, if we could afford to do so, not only is it the moral thing to do, but it would also be one of the most powerful things we can do to fight terrorism. Imagine what would likely happen if we showed the world that a primary function of our nation is to improve the health of all peoples at home and abroad. This would be a major step toward winning the hearts and minds of all peoples, including those who aren’t very fond of us right now; and, at the same time, it would make it much more difficult for terrorists to demean us and recruit individuals who want to destroy us.

So, assuming what I just said is valid, then how can we afford to be the leaders in promoting greater health and better healthcare for everyone around the in our own country and around the world?

There are many things we can do to get the money needed; some of which require a shift in our national priorities, policies and processes. Three of the more obvious strategies would be to:
  • Take some of the money currently being spent on weapons and the military to fight the “war on terrorism” through destruction and death, and use these funds constructively to improve health in the world.
  • Remove waste from our current healthcare system by fostering wellness and the delivery high-value care, which would save huge amounts of money, some of which could be used for “world care.”
  • Work with foundations and collaborate with other countries.
Click here for part 3 of this series.


Anonymous said...

Well Steve, you got me to follow a link! I can not add much to this since we know where the tough parts are and you articulate them well. I would like to start with the general coverage you propose but I think it would come into being with the slightest majority. That would excite a more extremeist minority that could follow their successful tactics of recent and present regimes. The results would be legislative sabotage of the program over a period of 4 to 12 years.

Anonymous said...

Way to go Steve!!! For me Universal Healthcare includes every single human being on the planet rich and poor alike. Now here is some good news about making universal Healthcare affordable. One issue I will be addressing very soon on my Blog is the promising treatment modalities and technologies that have been deliberately suppressed by greed. We must explore every single possibility of treatment or cure to its fullest potential without allowing self-serving special interest lobbies to subvert the truth or manipulate valid data for Corporate profit. There have been some very promising treatment modalities suppressed and abandoned without a full unbiased research opportunity because cheap effective treatment did not provide drug company profits.
One frequently overlooked fact is that once a universal Healthcare system overcomes the backlog of untreated patients, those who have let chronic disease become firmly established to the point where it is far more expensive to treat, then good early detection will start to reduce the cost of care. Bear in mind that right now at the most expensive point of treatment, the end stage care, the government does pay; what could be saved by reducing the burden of terminal care? Early detection and more affordable early stage treatment of disease represent a reduction in the overall cost of care.
Who really thinks we are saving anything by excluding migrant workers from access to care? Believe me, any single excluded group represents the potential breeding ground for an infection that could wipe out every single man, woman, and child in the US! There is strong evidence to support this fact. The US had almost completely eliminated TB until they turned mental institution patients onto the street, who were joined by disturbed returning War Veterans, the poor, the sick, the migrants and everyone else who fell through the ever widening cracks. A sea of discarded people became an ocean of potentially very easily infected individuals. Plus there was the AIDS crisis and rampant substance abuse; pretty soon we had established a really efficient breeding ground for multiple drug resistant TB and numerous other infections. So, are we saving a buck or two? I don’t think so! This still represents America’s Achilles heal: our extraordinary susceptibility to the rampant spread of infection in a pandemic due to our greed. Please visit this section on my Blog: http://medteam.wordpress.com/tag/disaster-preparedness/
On a more hopeful note there are issues we can tackle immediately and one is the “Deliberate Negligent Understaffing” of our Medical facilities. There is money to cover the cost of safe adequate levels of staffing, but we need to GUT top Heavy Management and drastically reduce the obscene CEO salaries: Healthcare does not need these excesses to function properly! Regular citizens must demand this major change in strategy before we squander more money paying Nursing Agencies ridiculous commissions to bring back the staff who were once part of the regular work force! We need proper safe Nurse to patient ratios, an end to exploitive practices like mandated overtime and unlimited hours of continuous duty without a break; we also need strong Whistleblower protection laws for Healthcare workers. Flawed tactics in the past have bloated Corporate profits while the dramatically increased risk of medical errors has been ignored at the expense of safe patient care. We must act now go to:
Please visit my Blog to read about other positive strategies for change in Compliance accountability and worker participation:

I have also written a piece on my Blog regarding “Medical Risk” and a C change with regard to coverage for Medical errors that is less punitive and encourages transparency. My suggestion would make the consumer equally responsible for poor outcome with regard to their personal compliance with treatment including the compromising factors like smoking. Go to:
However, before the point of service, Medical treatment, the cost of potential future treatment should be leveled at Companies. Tax cigarette Companies and even junk food vendors for the cost of future complications. Don’t worry they will pass it on to the consumer and higher prices will make bad habits less attractive. However, when someone requires care they become a special sacred entity in my eyes; I do not see the drug dealer, the thief, the gang member, the drunk driver, they are merely “the patient.” The patient, my patient, will always receive 100% best quality care regardless of who they are, rags, riches, bad habits, violence or filth, that is my duty and my ethical commitment as a Medical professional.

Dr. Steve Beller said...

Thanks for your powerful comment, Kim, and for the links to your innovative, action-oriented web site.

Since you are engaged in grass-roots advocacy, you may be interested in sharing your ideas about healthcare reform at the this link to the Unity08 agenda-building forum.

red said...

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