Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, April 28, 2007

Brief Foray into the "Health Care as a Right vs. Need" Discussion

Panda Bear and Emergiblog [sorry, Kim, but I can't find your specific posts; let me know and I'll edit/link], among others, have eloquently expounded on the topic of Health Care as a Right vs. a Need. This debate often brings up an analogy that I would like to point out is seriously flawed; too much so to be a valid comparison.

It is the analogy of health care to food, a subject near and dear to the hearts of many. The example is given that a commitment to subsistence nutrition does not equate to the right to walk into any restaurant and demand to be fed a five-course gourmet meal. "Basic" medical care available to all is considered the equivalent of not going hungry. This analogy is trotted out a lot, probably because it seems to make sense. Guaranteed health care doesn't have to be "all the bells and whistles;" just the "basics."

The analogy falls apart quickly, though. "Not starving to death" can be accomplished with a huge variety of diets costing anywhere from a few dollars to veritable fortunes per day. One's daily ration of calories (refusing to go into the whole issue of overeating/overnutrition for the purposes of this discussion) can just as easily be obtained by home cooking of thrifty supermarket purchases as it can by patronizing gourmet restaurants seven days a week. The utilization of excess resources to obtain a more exciting variety of food is irrelevant to the issue of starvation.

Medical care is different. Although it is tempting to talk about "routine health care" as things like immunizations and "routine checkups," the whole point of prevention is to detect health problems early and intervene before they become severe. Without including the means to deal with issues identified during routine checkups, "basic health care" is nothing more than a bad joke. What good is it to diagnose an early cancer without providing treatment for it? What good is providing treatment but no follow-up?

Medical care is like the part of the communist ideal that says "to each according to his need." No less, but no more. Advanced testing like MRIs or cardiac catheterizations are either necessary or not. Just because one can pay for it (or, more realistically, is able to purchase insurance that will pay for it) does not mean that unnecessary testing ought to be done. Conversely, patients with life-threatening conditions should not be refused ICU care because of their lack of financial resources.

Just throwing a monkey wrench into the arguments for and against "universal health care," "single payer," and other assorted attempts to solve the current mess that is the US health care "system."


At Sat Apr 28, 02:47:00 PM, Blogger Panda Bear said...

A family of four in Loisiana who qualify for "food stamps" (it's actually a card) get about $550 per month. If all we were concerned about was "basic food" (apropos basic health care) one can buy a fifty-pound sack of rice and fifty-fifty pound sack of beans wholesale for about twenty bucks and feed the family for six months.

Same with housing assistance. We could keep the poor in barracks if we just wanted the basics.

Besides, you're building a straw man. I don't believe we're comparing health care to food other than to suggest that if we're going to make medical care a right, why not food, cars, and other things people need?

Medical care cannot be a right because someone else has to provide it. If you're the only doctor in town, do you have to see everybody? What if you don't want to? Are you violating the rights of the sturdy townspeople?

At Sat Apr 28, 03:28:00 PM, Blogger Midwife with a Knife said...

It's obviously a complex issue, but I believe that the argument can be made that it isn't good for any of us to deny people health care. I would say that health care for the poor is almost as much as a societal good as police protection or roads.

For example, if we don't provide a way for people to have their pneumonia, strep throat, bird flu, leprosy, tb, etc. taken care of, we risk return to the conditions of the early 20th century where infections killed a large number of people.

In a way, providing health care for poor people is a form of sanitation. (aside from being the humane thing to do)

At Sat Apr 28, 04:28:00 PM, Blogger Panda Bear said...

I agree completely that we need to give charity to the poor for practical, civic, and religious reasons. But let's not give charity the imprimateur of an entitlement because once we do, we have just gone one step more towards turning our nation into just another European-style Freeloader Heaven.

If you think the Germans and the French, as an example, don't have problems paying for their cradle-to-grave nannyocracy then you have not been following the news, especially the last election in the Federal Republic.

Surely the best way to organize society is for people, as much as possible, to take care of themselves. If you think about it, most of the problems people get worked up about involve the simple problem of the productive sector of society not wanting to pay the bills of people who will sit on their rears angling for a disability check, the Holy Grail of the indigent.

At Sat Apr 28, 09:14:00 PM, Anonymous Anonymous said...

There are a number of medical services that can be kept out of "basic medical care." What about hip and knee replacements, treatment for ED, infertility treatment, insulin pumps for diabetes, stenting for chronic stable angina, epidural injections for back pain, etc. The list goes on and on. We can certainly establish a reasonable two tiered system that provides basic preventive care, emergency care, and necessary effective lifesaving procedures to everyone. The second tier of primarily "lifestyle" medical and surgical treatment could be available to those who can afford it. Who would make up the rules? Sit a few practicing physicians around a table for a couple of hours, and I think you would see a reasonable and affordable plan.

At Sat Apr 28, 09:41:00 PM, Blogger Midwife with a Knife said...

panda: I guess that part of the problem, from my perspective, is that we should maximize people's ability to be productive. And noninfectious. And part of that is health care. I personally don't trust charity organizations to do a great job of it. Not that the government's doing a great job of it either, really. It isn't always as simple as people freeloading. That freeloading diabetic mom who's 30 weeks is going to give birth to a brain damaged child if she doesn't get good care for her diabetes. I don't want to pay for that child's institutionalization/PT/OT (which can be extremely expensive). I want everybody to get vaccinated for rubella and varicella so that congenital rubella and congenital varicella remain problems of the past. Another freeloading mom's kid might be born at 30 weeks and require $100,000 of NICU care. Should that child die because we don't want to pay for his care or go blind because we don't want to pay for the laser therapy for his ROP? That kid hasn't done anything wrong yet. How can we ensure that everybody gets appropriate levels of care? Just hope some mishmash of charities picks it up? I don't like that idea. I'm happy to pay taxes to pay for health care for the poor. Maybe it's not run efficiently, maybe it has to be reorganized. I'll give you that. But I feel that public health is part of our infrastructure, and therefore something that we can reasonably take care of through govermental means.

anon: I think that's what the state of Oregon tried to do, and it hasn't worked out great for them.

At Sat Apr 28, 11:31:00 PM, Blogger Panda Bear said...

I mean government charity, not private charity. When we give medicaid to poor children, for example, that's charity.

At Sun Apr 29, 07:53:00 PM, Anonymous Anonymous said...

"Medical care cannot be a right because someone else has to provide it."

And this is different from food... how? Someone has to get up at the crack of dawn and milk those dairy cows. Someone has to feed the hogs and pick the lettuce and grow the strawberries.

I daresay farmers work just as hard as any physician, yet they see the middleman (i.e. the food processing companies, the grocery distributors, etc.) taking a bigger and bigger slice of the pie. Just like the health insurance plans.

You're gonna have to try harder because I'm not buying into the "woe is me, I'm just a physician slave in a cruel communist world" argument.

At Mon Apr 30, 01:41:00 AM, Blogger Panda Bear said...

And your point is? I never said food was a right either. Nothing that someone has to provide can be a right. I don't think you understood what I said at all.

As for "woe is me," are you saying that you would force a physician, alone among free citizens, to work for free to provide your right to medical care? How about nurses? They're pretty important, indispensible, as a matter of fact. How about them? Should they get paid if it comes down to it?

Your trouble is that you are unjustifiably envious of anyone who does better than you do. I suppose if you spent as much time, effort, and money as physicians do to arrive at the point where they can get paid well (four years of college, four years of medical school, and four years of residency in my case plus $250K of debt and zero assets when I'm done to show for it) you'd think differently.

As if I don't already work for peanuts (as a resident) and see thousands of patients who will spend like kings for cigarettes, crack, booze, or a thousand things that they value more than their health.

At Mon Apr 30, 04:17:00 PM, Anonymous Anonymous said...

you have identified the root cause of the problem. No one wants health care, at least not like they want $300 tennis shoes, $500-$1500 courtside tickets to a basketball game, $200+ dollar jerseys and requisite bling to wear to the game. And let's not forget the $8 beers, the $7 hot dog and maybe even some Rx treats before the game!
Then there are the multimedia cellular connections necessary to use to communicate to someone what is alreaady being aired on ESPN; the list goes on and on.

I don't have a problem with people making those choices-that's their right. But...making a choice should mean accepting the consequence of that choice.

How do return to a society that accepts accountability for personal behavior?

At Mon Apr 30, 08:42:00 PM, Anonymous Anonymous said...

For all that arguing, I still want to say to Dino: "hear, hear."

At Mon Apr 30, 08:57:00 PM, Blogger #1 Dinosaur said...

For all that arguing, I still want to say to Dino: "hear, hear."

*rubbing wax from ears* Eh?

I wasn't actually taking sides in the argument. I apologize to Panda, implying that he was making an analogy (health care to food) when in fact he was only giving an example of something else that is a need but not a right.

Central to the entire discussion: health "insurance" is not "health care." I've recently read some disturbing statistics about a proportion of the uninsured who simply choose not to spend their money that way. (Part of me can't blame them.) I've said all along that I'd like to see health "insurance" work like actual "insurance;" for catastrophes only and not for routine care. That would mean the vast majority of my services would be paid out of pocket by my patients. Numerically, I would come out ahead.

At Tue May 01, 03:45:00 PM, Anonymous Anonymous said...

In too many cases, the folks who come to my door or the door to the hospital Urgent Care I moonlight at demand care as a "right" are the ones who refuse to pay the bill!!!

Is it their "right" to receive care when they haven't paid for all the care they've received previously? Is it their "right" to ask me to provide a service with no or very low probability I will be reimbursed for that service?

Charity is to be given by free will of the giver, not to be demanded by the reciever. In this country, it is far too much the latter rather than the former.

At Wed May 02, 07:27:00 AM, Blogger Sara said...

Damn, Dino, all the issues you've put up lately are on my mind too. It was insane what was happening for Medicaid recipients in NY. I'd like someone to send a car and driver to get me to my appointments and massage and acupuncture. Then, working people, immigrants making $20,000 a year who don't qualify for anything, are having to buy their blood pressure drugs on the black market. Something is screwed up there.

One of the most useful lectures in medical school was about why healthcare as a free market supply and demand system doesn't work. One of the reasons was this - once people are into the system, they use more and more, and demand more and more. The hospitals here went nuts once a patient was on Medicaid - no test spared, no attempt to use cheaper drugs...because it was all paid for.

At Wed May 02, 10:26:00 AM, Blogger Panda Bear said...

Yeah, but the hospital "going nuts" is an example of why a true free market system for medical care would be, for most people most of the time, cheaper and more efficient. (Except, of course, that many people think that they shouldn't have to pay anything at any time for any medical care ever.)

In other words, the hospital goes nuts becasue their incentive for restraint (efficiency) has been removed. The market in this case is not free as the buying and selling decisions are independent of the the percieved value. It's more an example of how government intervention makes markets behave irrationally as pricing is set by a bureaucrat and not by the collective wisdom of millions of transactors.

I suspect your lectures in medical school were given by somebody who advocated some brand of socialized medicine and doesn't understand economics. Using medicaid as an example of a free market system is perplexing. A free market system is one where everyone pays for their own health insurance (to whatever extent they feel the need to cover their risk) or either borrows or pays up front for all of their medical care.

In such a system, which for political reasons would be impossible to implement, I betcha health spending would be a fraction of what it is now.


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