I have to admit I often have found the language of health care “rights” off-putting. Yet the idea of health care as a “right” is usually pitted against the idea of health care as a “privilege.” Given that choice, I’ll circle “right” every time.
Still, when people claim something as a “right,” they often sound shrill and demanding. Then someone comes along to remind us that people who have “rights” also have “responsibilities,” and the next thing you know, we’re off and running in the debate about health care as a “right” vs. health care as a matter of “individual responsibility.”
As regular readers know, I believe that when would-be reformers emphasize “individual responsibilities,” they shift the burden to the poorest and sickest among us. The numbers are irrefutable: low-income people are far more likely than other Americans to become obese, smoke, drink to excess and abuse drugs, in part because a healthy lifestyle is expensive, and in part because the stress of being poor—and “having little control over your life”—leads many to self-medicate. (For evidence and the full argument, see this recent post). This is a major reason why the poor are sicker than the rest of us, and die prematurely of treatable conditions.
Those conservatives and libertarians who put such emphasis on “individual responsibility” are saying, in effect, that low-income families should learn to take care of themselves.
At the same time I’m not entirely happy making the argument that the poor have a “right” to expect society to take care of them. It only reinforces the conservative image (so artfully drawn by President Reagan) of an aggrieved, resentful mob of freeloaders dunning the rest of us for having the simple good luck of being relatively healthy and relatively wealthy. “We didn’t make them poor,” libertarians say. “Why should they have the ‘right’ to demand so much from us?” Put simply, the language of “rights” doesn’t seem the best way to build solidarity. And I believe that social solidarity is key to improving public health.
Given my unease with the language of rights, I was intrigued by a recent post by Shadowfax, an Emergency Department doctor from the Pacific Northwest who writes a blog titled “Movin Meat.” (Many thanks to Kevin M.D. for calling my attention to this post.) Shadowfax believes in universal healthcare. Nevertheless, he argues that healthcare is not a “right,” but rather a “moral responsibility for an industrialized country.”
He begins his post provocatively: “Healthcare is not a right…I know this will piss off” many of my readers, “but I wanted to come out and say it for the record…My objection may be more semantic than anything else, but words mean things and it is important to be clear in important matters like these.”
Anyone who says that words are meaningful has captured my attention. I’m enthralled. After all, words shape how we think about things. Too often we automatically accept certain words and phrases, without realizing that they define the terms of the argument.
Shadowfax then quotes from a reader’s comment on his blog: “Jim II said it well in the comments the other day: ‘rights are limitations on government power.’
“Exactly,” writes Shadowfax. “When we use the language of ‘rights,’ we are generally discussing very fundamental liberties, which are conferred on us at birth, and which no government is permitted to take away: free speech; religion and conscience; property; assembly and petition; bodily self-determination; self-defense, and the like. Freedoms. Nowhere in that list is there anything which must be given to you by others. These are freedoms which are yours, not obligations which you are due from somebody else. There is no right to an education, nor to a comfortable retirement, nor to otherwise profit by the sweat of someone else’s labor.”
Normally, I would object: Americans do have a right to an education. But Shadowfax is defining our “rights” in a very specific sense: our constitutional rights make us, as individuals, free from something—usually, interference by government, our neighbors, or the majority in our society.
Shadowfax then turns from the idea of rights to what people deserve: “some societies, ours included, from time to time decide that its citizens, or certain groups of them, should be entitled to certain benefits. Sometimes this [is] justified by the common good — a well-educated populace serves society well, so we guarantee an education to all children. Sometimes this is derived from humanitarian principles — children should not go hungry, so we create childhood nutrition programs. Healthcare would, in my estimation, fall into the category of an entitlement rather than a right…”
Here, we are no longer talking about our rights as individuals; instead, Shadowfax is asking us to think collectively about what we all deserve simply by virtue of being human. These are what I would call our “human rights,” which are quite different from our constitutional rights as individual citizens.
This is what Jim II is referring to when, after defining “rights” as “limitations on government power,” he writes: “That said, I think it is immoral for someone’s access to healthcare, politics, or justice to be dependent on how good a capitalist he or she is. And therefore, I think we should use the government to ensure that people from all economic classes are treated equally in this sense.”
In other words, a person’s access to medical care should not turn on just how skilled he is as an economic creature. While some of us are smarter, taller, and quicker than others, as human beings we are equal.
In the economy, the swift will win the material prizes; but in society, human possess certain “inalienable” rights to “life, liberty and the pursuit of happiness” simply by virtue of being human. These are different from a citizen’s “right” to free speech—a right that no government can take away. The framers of the Declaration of Independence believed that these “inalienable rights” are bestowed upon us by God. To me, this means that we have moved from the rule of law in the public sphere to the private sphere and those moral rules which begin “Do unto others . . .”
When Jim II argues we should “use the government” to oversee healthcare, and to “ensure that people from all economic classes are treated equally in this sense,” he is saying that government should oversee that moral compact among men and women who recognize each other as equals. Here I would add that, when comes to the necessities of life, a society that seeks stability and solidarity strives for equality.
Shadowfax goes on to point out that “our nation has long defined health care as an entitlement for the elderly, the disabled, and the very young. We are now involved in a national debate whether this entitlement will be made universal. As you all know, I am an advocate for universal health care. Though there may be an argument for the societal benefit of universal healthcare, or for the relative cost-efficiency of universal healthcare, I support it almost entirely for humanitarian reasons. It needs to be paid for, of course, and that will be a challenge, but as a social priority it ranks as absolutely critical in my estimation . . .”
On this point, I don’t entirely agree. In my view there is a very strong argument to be made for the societal benefit of universal healthcare; if people are not healthy, they cannot be productive and add to the wealth of the nation. And there is an argument for cost-efficiency—if we don’t treat patients in a timely fashion, they become sicker, and charity care becomes more expensive. But I would add that even if we are talking about a person who cannot be expected to add to the economic wealth of the nation—say, a Downs’ syndrome child who will need more care than he can “pay back” over the course of a lifetime—he is entitled to healthcare for humanitarian reasons. As healthcare economist Rashie Fein has said: “We live not just in an economy, but in a society.” And as a human being, that child can contribute to society, by bringing joy to his family, or by being in a classroom with children who will learn from him.
What of the “Rights” and “Obligations” of Doctors?
Shadowfax’ argument then takes a shocking turn. Without fanfare, he acknowledges that he has some sympathy for “the common line of argument against universal healthcare” which declares that, “with any good or service that is provided by some specific group of men, if you try to make its possession by all a right, you thereby enslave the providers of the service, wreck the service, and end up depriving the very consumers you are supposed to be helping. To call ‘medical care’ a right will merely enslave the doctors and thus destroy the quality of medical care in this country [...] It will deliver doctors bound hands and feet to the mercies of the bureaucracy.”
Here, Shadowfax is quoting from a speech by Alan Greenspan’s moral mentor, Ayn Rand, released by the Ayn Rand Institute in 1993 as a comment on the Clinton Health Plan.
In that speech, Rand denies that healthcare is either a right or an entitlement: “Under the American system you have a right to health care if you can pay for it, i.e., if you can earn it by your own action and effort. But nobody has the right to the services of any professional individual or group simply because he wants them and desperately needs them. The very fact that he needs these services so desperately is the proof that he had better respect the freedom, the integrity, and the rights of the people who provide them.
“You have a right to work,” she continues, “not to rob others of the fruits of their work, not to turn others into sacrificial, rightless animals laboring to fulfill your needs.”
If I find the language of “rights” troubling, I find Rand’s language terrifying. ) Shadowfax admits “There’s a lot not to like about this sentiment. But,” he argues, “it has some limited validity. . . .”
Shadowfax then turns to the predicament of his cohort—emergency room doctors. Under law, they are required to at least stabilize patients—even if those patients cannot pay. And most often, physicians go well beyond stabilizing them, treating them and even admitting them to their hospitals.
“Only problem is,” Shadowfax writes, “I and my colleagues are not caring for you out of the goodness of our heart, nor out of charity, but because we are obligated under federal law to do so. While this isn’t exactly slavery, this coercion of our work product is essentially compulsory if you work in a US hospital.”
What I like about Shadowfax is that he then moves from complaint to a potential solution: “Universal health care, or, more precisely, universal health insurance, might improve upon the current state of affairs by ensuring that doctors are always paid for the services we provide, rather than being obligated to give them away to 15-30% of their patients as we now are… The typical emergency physician provides about $180,000 of free services annually,” he adds, “just for reference.”
I’m not sure that the average ER doc should be paid $180,000 more than he is today. (I would agree that, when compared to many specialists, ER docs are not overpaid—and theirs is a very demanding job. But $180,000 seems a large sum; I don’t know whether taxpayers could afford it.) Nevertheless, I agree that the current law regarding ER care is an unfunded mandate—and one that hospitals located in very poor neighborhoods cannot afford. Moreover when ER doctors feel that they are being forced to deliver free care, many will be resentful. This is understandable, and does not lead to the best care.
On the other hand, in a society where so many are uninsured, I do believe that physicians have a moral obligation, as professionals, to provide some charity care. They have taken an oath to put patients’ interests ahead of their own. The problem is that the burden falls unfairly on those who are willing to work in emergency rooms or neighborhood clinics while many doctors in private practice simply shun the poor. We need a system that is fairer, both for patients and for doctors.
The answer, as Shadowfax suggests, is universal health insurance that funds ER care for everyone who needs it—and, I would add, health reform that restructures the delivery system so that Americans don’t have to go to an ER for non-emergency care.
In the end, I agree with Shadowfax that reformers need to think carefully about the language they use: “When advocates of universal health care misuse the language of universal rights to push for health care for all, we fall into the trap of over-reaching and provoke a justified pushback, even from some who might be inclined to agree with us. Universal health care is, however, a moral obligation for an industrialized society, and will not result in the apocalyptic consequences promised by the jeremiads.”
What I like about calling healthcare a “moral obligation” is that it presents healthcare, not as a right that “the demanding poor” extort from an adversarial society—or even as an obligation that the poor impose upon us. Rather, Shadowfax is talking about members of a civilized society recognizing that all humans are vulnerable to disease—this is something we have in common—and so willingly pooling their resources to protect each of us against the hazards of fate.
Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.
It doesn’t matter if health care is a right or not. We’re should and will provide every single person with health care, libertarians be damned.
I don’t think we need to define healthcare as a right in order to have universal access single-pay, just a societal commitment. Canada does not specifically define healthcare as a right in it’s Charter of Rights and Freedoms. Making it a right restricts the use of reasonable cost controls. But in the U.S. it is clearly not defined as a right, yet there seems no shortage of people who demand and get thousands of dollars of medical care to extend end of life a few months. Was there an explicit right to endless medical care for Terry Schiavo, certainly the “right-to-lifers” thought so. Is there a defined right to education needed to make sure we all have access, no matter our economic circumstances? Does a doctor have a right to refuse to give care in a roadside accident because he may not get paid? If doctors think that having government controlled healthcare takes their “right” away to determine their charges and income then I guess they have a right not to enter into medicine or just to find another career.
I get all this, however- as a doctor- I am considering the quality of care, or lack thereof, universal care would mean for our patients right now; I strongly advocate for all of us to get past our partisan biases and “clean up” the health care system- and the billions of dollars of excesses and waste- and for the comment from kazumatan, please don’t eliminate freedom of choice- and please don’t insult our libertarian friends- about health freedom they are 100% correct. In a reformed system there will be more than enough health care for all.
On December 10, 1948 the General Assembly of the United Nations adopted and proclaimed the Universal Declaration of Human Rights:
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.
—-
This seems clear enough to me.
-Mark
The argument about rights is incomplete without at the same time addressing personal responsibility. There is a balance we need to maintain between what is provided for us, and what we provide for ourselves. When that balance is skewed to either side, we have problems.
Dr. Mary, the working problem with freedom of choice in a two or multi tier health system is the public funded universal one gets starved of cash, while the money and influence of the elite system gets the best care. So, I’m not sure I understand your “choice” definition or the reason for it.
Deron, personal responsibility is desireable, but I’ve never seen many people apply it without having a punishment and oversite system to remind them that there are consequences for not exercising it. Hence we get the advocates of personal responsibility icons of Wall Street stealing billions. For instance, I advocate a tax on fast food, that way people can apply good choices or bad choices, but the bad choice will remind them there are society costs involved.
Let’s keep it simple. Recently, someone (I think it was a woman, but I can’t remember who that was – not Gov. Palin) said: we are not a society that lets bodies pile up in front of the ER. All philosophy aside, most people in the US have the basic decency to admit to that.
And that makes me wonder about shadowfax’ attitude. ER physicians are usually not paid based on production (please correct me if I am wrong here).
If he does not want to be coerced in seeing patients for whatever reason (e.g. finacial reasons, avoiding “unpleasant patients”), he could go into a different specialty or try to move into an area where the unpleasant or uninsured patients will be less common. As an ER physician, one is part of the first response system – a police officer, paramedic or firefighter cannot simply refuse getting in touch with smelly or dangerous people.
Maggie, this is a great post. It’s nice to see honest discussion about rights. Too often we are boxed into thinking that everything is either a right or a privilege, that we forget that there are other categories in life.
I have one question. It’s nice to hear that you don’t support unfunded mandates on doctors, which bring us a step closer to enslaving them. So instead you support increased taxation to fund doctors more. But doesn’t taxation just shift the burden? Instead of enslaving doctors, aren’t you then slaving other people to pay the doctors?
I think everyone should have the right to health care and the US should have a national health service
This post and most of the comments exhibit the general ignorance that exists in the US about the concept of human rights in general and the right to health in particular.
As Mark points out, the right to health is part of the Universal Declaration of Human Rights. It is also further defined in many other international conventions, especially the International Convention on Economic, Social and Cultural Rights, which the USA has signed but not ratified.
You can say “freedom of speech” isn’t a right, that that doesn’t make it so.
Human rights as defined by a long ethical, philosophical and legal tradition (about which should learn something before you write an article on the topic) always include rights and duties. The state is the ultimate “duty bearer”, but each person/entity has both claims (rights) and duties.
We should have a comprehensive universal health system in the US because health is a right, and because it is good for us to all be healthier, and because it will cost less.
I think that we are getting tied up in the semantics of “positive” vs “negative” rights. Both should thought of as rights, but our tradition in the United States has definitely focused on guaranteeing negative rights to US citizens. Negative rights put limits to what the government and citizens can do to one another. For instance, the government cannot dictate our religion, cannot censure us, and we cannot kill one another.
Positive rights, on the other hand, guarantee something for citizens. For example, guaranteeing a minimum level of primary health care to all citizens would be a positive right. Positive rights have been more widely acknowledged by socialist countries and less by the United States.
It is much simpler to guarantee negative rights than positive rights; just as it is easier to prevent someone from doing something rather than guaranteeing access to something for everyone equally.
I strongly believe that both positive and negative rights must be considered in discussions of health care reform. The only body that can grant and guarantee rights are sovereign governments – no private entity can guarantee a right to health, or freedom of speech for that matter – and for that reason I think that it is incredibly important that we talk about health as a human right.
If words are so important, then we should be using words that are specific and mean exactly what we are trying to say. Health care is a human right. Therefore it is the responsibility of (and an ultimate benefit to) the society as a whole to guarantee that right. Describing health as a “moral obligation” is vague enough to enable the current half-assed attempts at universal coverage to continue. Who’s obligation is it anyway?
The fact of the matter is that some people exercise their “rights” more frequently than others. As an ER nurse I can tell you that we have “regulars” with chronic complaints who are non-compliant with any type of treatment. This includes the people who want detox (for the 19th time this month); alcoholics who want a warm place to sleep it off; dialysis patients who skip their appointment because it was not convenient and are now short of breath; people who saw their doctors at 10:00am in the morning and are not cured by 4:00pm after only taking one dose of medicine; and finally, the Mom whose child has a fever but she can’t force him to take Tylenol because she doesn’t want to psychologically scar him (but its ok if we force him).
If I sound cynical maybe its because I am tired of hearing the word “rights”. Before anyone bellows at me about their rights let me first ask them what they have done to sucure the rights of others. Everyone has the right to healthcare but they do not have the right to abuse healthcare or the people who provide it.
Zina, as much as I sympathize with your frustration (I briefly worked in an inner city ER during my internship, and also in addcition psychiatry and I think I know what you are talking about), I don’t think that the ER abuse should be an argument against universal healthcare (such as insurance fraud is not a convincing argument to call for an end of all insurance policies, or the abuse of sick days etc).
ER abuse could be drastically reduced by strengthening primary care and by associating walk in clinics with the ER (and the latter should charge convenience fees for after hour visits). But I think it is a separate problem.
Two points to keep in mind:
1) Government programs are all constrained by limited resources. If we decide to fund universal (or something closer to universal) health coverage, there is a huge cost to that. It’s morally irresponsible to couch the discussion of universal health coverage as ‘good’ or ‘nice’ and all those against it as ‘bad’ or ‘mean’. (and a host of other euphemisms being used this election year) as it simplifies the underlying dilemma of trade-offs. Where does the funding come from? If we take the money for universal health coverage from another government program that is providing some other ‘right’ to its citizens – such as social security, physical security, education, etc. And even if a magical, ever-green funding source is found — rising medical costs are going to continually put pressure on the U.S. system until we address that.
2) Other point is unintended consequences – i.e. Zina’s point about people abusing the system (though as rbar said, abuse of the system alone is not cause to reject a universal model). Additionally, a limit to the moral obligation is necessary. I may give my neighbor a ride to work, but I’m not going to give him my car. Similarly, we have to guard against giving everyone the cadillac of free medicine when the toyota would have sufficed.
Just because the UN says something is a “right”; doesn’t mean it is so.
Answer this, can something be a right if it requires enslaving someone to provide you that right? Apparently, the UN and Mark, Laura and rbar think so.
Regarding positive vs. negative rights … if I’m reading this correctly, a negative right ensures that you won’t be forced to do, say, or believe something; whereas a positive right is something that force other people to give you to you, because it’s your right to have it (read: take it).
This post is a GREAT post, and I totally agree, health care is a “moral obligation” … providing health care is no different than the US deciding that we can’t let old people, who don’t save for retirement, be destitute at old age, so we provide social security.
Social security isn’t a right, it’s a moral obligation, also called an entitlement.
Oz, universal coverage is not about robbing another necessary government program so we can give it to healthcare. Universal coverage, to be done correctly, should trade dollars we now give to insurance companies and use that as taxes for healthcare. We could just roll everyone into Medicare and have each state manage it locally. But if we do not control costs and establish health budgets then trying to fund healthcare either with private plans or public money will bankrupt us anyway.
Marco,
I don’t know from which statement in my previous posts you deduct that I want to “enslave people”. If you have the courtesy to be more specific, you would give me a chance to reply.
I frankly don’t think that the word “slavery” is at all appropriate in the context of governmental services/taxes. Would you say that you are “enslaved” to pay for national defense or the legal and executive system? I personally think that the US is overspending on defense and is incarcerating too many people (and I don’t feel that all of my tax dollars are wisely spent). And yet, I would never state that the US is “enslaving” me to finance the Iraq war, or a military apparatus that is in no relation to the military threats the US faces.
However, you indicate that you are alright with SS, or at least that it is not based on slavery. But is it a voluntary program?
And by the way, I wholeheartedly agree with MM’s post, especially the first 2 paragraphs.
Re. charity care: I am currently in an area where I have to provide very little charity care, even though I have signed up with the local free clinic. A physician can largely avoid to provide charity care, depending on his/her professional choices. Do I find it fair that some physicians get barely (medicaid) reimbursed, or not at all? Of course. But in that context, the discussion should focus on the varying insurance and reimbursement variations/problems in this country, not on the fact that ER physicians cannot refuse to treat unstable patients, which, in my opinion, is an integral part of being an ER physician, if not of being a physician in general.
Don’t call it a right. From a practical standpoint, you then have to perform mental gymnastics to justify why you have to tell certain patients who supposedly have a “right” to something why they can’t get it. If it is a “right”, why can’t you demand that whatever treatment you want – no matter the cost or odds of success – must be provided to you? Do you have a “right” to demand that you get a heart transplant at age 100? This is an extreme example, but look at some of the real-life extreme cases we have seen in end-of-life matters lately. In Austin recently a dying infant was kept alive on aggressive artificial life support in a pediatric ICU even though his brain was basically destroyed because the mom insisted that everything had to be done, even if it meant going to extremes. Did this mom have the “right” to demand the taxpayers cough up $1.7 million to cover this tragic and pointless extension of a toddler’s dying? Did the same mom have the “right” to demand that doctors and nurses provide senseless treatments they thought violated their medical ethics and Hippocratic oath?
Call it a societal benefit, if we must call it something. This makes clear that the larger society can place reasonable limits upon that which it will provide. It may even add some responsibilities to the mix, like requesting that cardiac patients please stop smoking if we are going to do all that fancy bypass work.
People understand that benefits are not without limits and that benefits must be balanced against other societal needs when setting budgetary priorities. In short, calling something a benefit means we can more easily say “no” when it is appropriate. It is much harder to tell someone they can’t have something they consider a “right”, as they may feel their “rights are being violated.”
I also tend to fall into the group that views true rights as innate, meaning you have no need of anything external to possess and use them. One way of explaining it is the desert island scenario. Imagine you are alone on a desert island. Now pull up a copy of the Bill of Rights and see if any of the listed rights are null because you don’t have a larger society to provide you with something. Free speech? Still got it. Freedom of religion? Yup, still here. Right to keep and bear arms? Even though you have nothing to shoot at but your next dinner, you can still pack heat until the bullets run out. None of the items set out in the Bill of Rights goes away if you are by yourself on the island.
Now add in a “right” to health care. OK, who provides it? Suddenly your rights go from something “endowed by our Creator” innate to something that requires an external support system (including other people agreeing – or being coerced – to provide your medical care). Your right to something cannot be freely exercised because it needs a government to use its powers to make sure you get it.
Sometimes government are perfectly justified in using their powers to provide for the common good. A military and a police force are examples of societal benefits provided to citizens and we are taxed to pay for them.
Even these essential functions are seen as societal benefits. Health care should be regarded in the same context. We can then have a rational discussion on how far this societal benefit should be extended, which can include cost and the reasonableness of the treatments offered as considerations.
I’ll come back to respond to specific points later (have to write a post right now.)
But thanks for the many comments–
Let me say, regarding the UN’s declaration that “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family . . .”
What does that mean? What is adequate? What counts as well-being?
Here is a tough example, but one that crops up with some frequency in the real world. A child is born with
a facial deformity–let’s say he or she has no nose.
Does that child have a right to the best plastic surgery that we can provide, which would mean that we give him or her a nose that looks almost natural?
Or do we just do the surgery necessary to make sure she can breathe easily and leave the child with two holes in her face where a nose should be? (My daughter is a teacher, and in her first grade class she had a very poor child,probably on Medicaid, who had two holes where the nose should be. . .)
If you argue that healthcare is a “right” not everyone would agree that the child has a legal “right” to the best plastic surgery. Yet I would guess that most of us, looking at this child, would feel that we have a moral obligation to help this child . . . This is a case where “Do unto others” clearly applies. That’s what I mean by a societal moral obligation–in a civlized society where we emphahize with each other as human beings.
As for health care reform– if we cut the waste out of the system (about $1 out of $3 dollars is wasted on ineffective, unproven, often over-priced drugs, devices and treatments that are no better than the less expensive treatments they are replacing)–we would have plenty of money to give everyone high-quality, effective care. And no one would have to be “enslaved.”
Unless you consider making less than $600,000 a year “slavery.” (We are over-paying for certain procedures performed by some specialists–and we’re underpaying for care provided by primary care docs, pediatricians, palliative care specialits, psychologist, geriatricians . ..The fee schedule needs to be adjusted with a scalpel–redistributing some dollars. )
Finally, giving everyone health Insurance is not equivalent to guaranteeing them health Care. So universal coverage (making sure everyone has a piece of paper called insurance, no matter how inadequate it is) is not the be-all, end-all of reform.
Words are important. And, calling health care a “right” has never seemed quite proper to me. As a society we have a responsibility not to allow any of our neighbors to go untreated because he or she on a particular day or year did not have enough money to pay for medical services or health insurance. The best words I can come up with are we have a “social responsibility” to see that everyone gets health care. For the individual, it is a “social benefit”, not a right, privilege, or entitlement.
Now it becomes an economic issue. Everyone gets Medicare. Everyone with income sees a contribution line on their paycheck or 1040 that says “Medicare”. Smart, decent people, with complete transparency decide what services, devices, and medicine are provided by Medicare. By the way, there are still smart, decent people in the world.
Doctors and other Medicare providers get paid by the hour. They can either choose to be government employees or set up their own businesses providing Medicare services. The government employees and private businessmen are regularly reviewed to make certain they are providing acceptable service for each hour they are paid. If they don’t perform well, they are fired.
Everyone has to pay for Medicare whether they use it or not. If you don’t like it, you can buy whatever you want from a private business doctor. It’s not much different than choosing to pay for a private school rather than go to a public school. No, you don’t get any vouchers or credits for not using Medicare, just as you shouldn’t get them for not using the public school.
Will all the smartest and best doctors want to be private doctors? Sure, go for it. But you are going to have to compete with the Medicare providers, who do not all have to be MDs from AMA authorized medical schools. There are plenty of people who are able to most of what doctors do, could be educated in four or five years, and would be happy to do it for $150,000 or maybe even $80,000 a year with full benefits.
Is this “socialized medicine”? Sure, whatever. Words are important, remember, so call it Medicare or something else. Will this ruin the incentive for people to become brilliant surgeons, because don’t have the potential to make more than a million dollars a year? If someone has to make more than a million a year, there are plenty of ways to do it outside of medicine. Health care is too important, just like national defense, or, let’s see, what else comes to mind because it has been in the news lately?-…oh yes, our banking system — to turn it into a money-making, manipulated, free for all.
This is pretty much how the rest of the civilized world does health care. And, by every valid measure, does it much better.
rbar,
I am merely pointing out that calling health care a right, requires someone else to provide it to you. It requires someone to work for you. Rights are things you are born with, that no one can take away … freedom of speech for example. I am not required to work to provide it to you, you simply have it.
I am ok with social security and all the other spending because we do not call them rights, they are entitlements. As such, I am trying to make the point, that health care is that a society should provide, based on it’s ability to do so.
I talk about enslavement in absolute terms, some ‘universal health care systems’ don’t allow doctors to practice for themselves … they are required to work for the state … whether you’re paid in food and shelter, or 600K; this notion stinks of enslavement.
“they are required to work for the state …”
No, they can make a choice, if they don’t want to “work for the state” they can chose another career. Just because they are paid by the state does not mean the state controls their medical practice. In Canada doctors negotiate reimbursement and “the state” pays them for every patient they see and they don’t have ANY collection issues or bad debts. Getting paid by the state and billing ONE insurance provider (the state) also means the practice is more efficient with less employees doing paperwork jobs. In Ontario “the state” also pays HALF their malpractice insurance. Not bad eh, for, “stinking of enslavement”. Are road builders enslaved by the state because the only way they can get paid is from the state through state business?
Posted by: Maggie Mahar: “Let me say, regarding the UN’s declaration that “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family . . .”
What does that mean? What is adequate? What counts as well-being?”
My point is that people have been working on answering those questions since the UDHR was signed. The answers are fairly well defined. If anyone is interested to read about what the right to health actually means, I refer you to the following resources:
http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En (The text of the General Comment on the Right to Health)
http://www.who.int/hhr/activities/publications/en/ (World Health Organization publications on the RTH for the general public)
For example, the Core Obligations of the state relating to the RTH are:
43. …
(a) To ensure the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups;
(b) To ensure access to the minimum essential food which is nutritionally adequate and safe, to ensure freedom from hunger to everyone;
(c) To ensure access to basic shelter, housing and sanitation, and an adequate supply of safe and potable water;
(d) To provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs;
(e) To ensure equitable distribution of all health facilities, goods and services;
(f) To adopt and implement a national public health strategy and plan of action, on the basis of epidemiological evidence, addressing the health concerns of the whole population; the strategy and plan of action shall be devised, and periodically reviewed, on the basis of a participatory and transparent process; they shall include methods, such as right to health indicators and benchmarks, by which progress can be closely monitored; the process by which the strategy and plan of action are devised, as well as their content, shall give particular attention to all vulnerable or marginalized groups.
44. The Committee also confirms that the following are obligations of comparable priority:
(a) To ensure reproductive, maternal (pre-natal as well as post-natal) and child health care;
(b) To provide immunization against the major infectious diseases occurring in the community;
(c) To take measures to prevent, treat and control epidemic and endemic diseases;
(d) To provide education and access to information concerning the main health problems in the community, including methods of preventing and controlling them;
(e) To provide appropriate training for health personnel, including education on health and human rights.
45…. the Committee wishes to emphasize that it is particularly incumbent on States parties and other actors in a position to assist, to provide “international assistance and cooperation, especially economic and technical” (29) which enable developing countries to fulfil their core and other obligations …
The Covenant also provides for progressive realization (the state has to make reasonable progress, not transform overnight) and acknowledges the constraints due to the limits of available resources.
“they can make a choice, if they don’t want to work for the state they can chose another career.”
This is only the case for people who aren’t doctors yet. People who have already completed training, and were hoping to work privately, will be enslaved plain and simple. And from that point forward, only people who don’t mind working for the state will become doctors…those won’t be the smartest minds in the country.
“Just because they are paid by the state does not mean the state controls their medical practice.”
Consider how much the state already controls medical practice. By determining doctors’ salaries through medicare, the state has created the situation in which there are lots of specialists, and everyone wants to go into dermatology and plastic surgery, while there are few primary care doctors. In Europe, the state controls even more…it can tell doctors which drugs they can and cannot prescribe.
@ Peter …
“Are road builders enslaved by the state because the only way they can get paid is from the state through state business?”
No, road builders can chose to build private roads, driveways, pour foundations for homes and commercial buildings. Doing work for the government isn’t their only option, they can choose who they work for … they aren’t enslaved.
But my point is more to the fact that if a right requires someone to work to provide it to you, then you are enslaving that person. We require people to pay taxes to pay for things like Social Security, BUT we do not call social security a right.
@ Laura,
Just listing more vague language by the UN doesn’t make your case. I followed the links and skimmed the documents … just more vague language.
Is bypass surgery a right, what about angioplasty? Who has a right to these? Does a 98 year old have a ‘right’ to these? If you don’t have unlimited funds, who gets the surgery, a 50 year old or the 98 year old? If it’s a right, is it fair to discriminate, shouldn’t everyone be able to get this surgery?
In Europe they control costs by limiting access to certain elective surgeries like hip and knee replacements to very old citizens … my 87 year old Aunt in the US just had her 2nd knee replacement last year … is that a right, will that be a right that is protected?
Rights are boundless, so long as your rights don’t infringe on my rights. Trying to claim health care as a right fails this test … practically speaking, you can’t provide boundless health care.
Hi Marco,
In regards to your freedom of speech just being “given to you”, without anyone else having to “work for you”, I think we should look into whether that is really true. Think about it, don’t we have a massive government infrastructure, freedom of speech watchdog groups, etc. working everyday to make sure you are granted those rights? Although, you may argue that you deserve those rights as soon as you are born, they still do require a concerted effort – and people working – to guarantee them.
My argument is not much different. I believe that every human being is born with the right to live a healthy life. To achieve this will require a sizable investment by our society. But lets look at the returns. A healthier society is more economically productive. In addition, I believe that equitable access to health care would actually reduce the amount we spend on health care in this country. Because nearly 1/3 of the US population has no health insurance, those people tend to wait longer before seeing a doctor and hence are much sicker when they do seek treatment, requiring more expensive interventions. And, the idea that an ER is equivalent to a primary care physician – I cannot imagine a place more ill suited (and honestly dangerous due to taking time away from serious injuries) or expensive to use as a general doctors office.
Finally, I think that health is largely structured by poverty. Poor people are both sicker – due to environmental forces that people in poverty must endure – and also, generally do not receive the treatment they need. Basically, the people most in need of treatment do not have access to it for economic reasons. We can go around and around about whether angioplasty or knee replacements should be provided to anyone, anytime (I think probably not) but these are the people – people living in poverty or close to it – that will most benefit from simply being able to see a doctor on a regular basis. By not providing everyone the human dignity of a right to basic health care, we continue to propagate the cycle of poverty and injustice.
Jon,
Freedom of speech, rightly understood, is the idea that no one should actively stop you from saying what you want. That doesn’t require any effort on anyone else’s part. It might require effort on YOUR part…because you have to make sure to get a microphone, or start a newspaper, or whatever…but that’s your responsibility, not anyone else’s.
The government’s only proper role in this is to stop other people if and when they threaten to actively stop you from exercising that right. The government groups don’t “grant” you that right. Their only job is to not take it away.
So it is very different from healthcare
Marco, if your point is road builders can chose other work not to be “enslaved”, then why is that not true for doctors?
Thanks for the many comments.
I’ll also be very interested in
seeing how the poll works out–
(Thanks Matthew & John– great idea)
Let me respond to some of you individually:
Peter, you wrote “Making it a right restricts the use of reasonable cost controls.”
This is true. When you use the language of rights, you encourage individuals to think that they have a “right” to any treatment they want–or think they want.
Turn it around, say that society has a moral resposibilty to provide everyone with the care they Need–and it becomes apparent that we are talking about effective care. No one has a right to every drug or treatment they see advertised on TV. As a society, we have a moral obligatoin to test and reserach new treatments– and then to provide the treatments that actualy work to the people who need them–providing the right care to the right patient at the right time.
Another example: today about half of the people who undergo anigioplasty don’t enjoy any long-term benefit from the procedure. Short term, it reduces their agina, but long-term, many of them would be better with a change of diet, exercise, and medication.
Neverthless many patients demand angioplasty because they want a “quick fix” for the angina. They don’t want to go to the trouble to change their diet, exercise, etc.
Do we have a moral obligation to pay for their quick fix? I would say no–as long as they can afford a healthy diet, the medication, and have a place to exercise.
Dr. Mary Zennett– I entirely agree. Just expanding a broken system and providing often ineffective and risky care for everyone is not the answer. We need to improve the quality of care, wring out the waste (ineffective care) and then, as you say, we can afford high quality, sustainable, affordable care for everyone.
I’d start by reforming Medicare–and make it a demonstration project for universal care. See my report on The Agenda: Getting More Value from Medicare on
http://www.tcf.org.
Deron S. — I’m not sure you read the post. You are correct that when we start talking about individual “rights” we quickly begin talking about individual “responsibilities.” In the post, I explain why that is a problem.
ray– you see to be wishing that we could go back to time when the doctor was always right and solo practioners could do whatever they wanted without anyone looking over their shoulder to ask– Is this benefiting the patient? Does he need this treatment?
before paying you.
That ship has sailed. Medicine has become a team sport–doctors have to collaborate with each other, which means looking over each others shoulders. And payers
are beginning to insist on “evidence based medicine”– they want medical evidence thay a treatment is likely to help that particular patient.
Have an appointment– but will return with more responses– this is an interesting thread . . .
Peter–
A tax on fast food is a good idea.
This, uy the way, is not a “regressive tax” that hits the poor hardest. Poor people (defined as a family of three living on $16,000 or less) CANNOT AFFORD TO EAT McDonalds. EIGHTEEN PERCENT OF CHILDREN IN THE U.S
LIVE IN POOR HOUSEHOLDS (Three people in the family, with a joint income from all socurces (including food stamps, social security etc of less than $16,000.)
They eat beans, rice and beans, bread, potatoes, potato chips, oil, peanut butter, pasta, etc. grilled cheese sandwiches, egg sandwiches– cheap foods that are filling and provide short-term energy, but, by and large, are not nutritious.
When people talk about how the poor should show more personal responsibility–and not eat at McDonalds–this tells me that the persona talking probably don’t know any families earning less than $16,000. a year. They’re talking about middle-class famlies– with joint incomes of, say, $45,000for a family of three.
Probably most of you are no longer reading
this thread — so I’m not going to try to respond
to individual comments (unless I hear from individuals who have been checking back–just let me know you’re looking for a response.)
But in general, let me just say that I view a “right”
under the law, as much, much less important and much less powerful than a moral obligation. Moral obligations are not legal obligations.
Laws are made by men. Moral obligaionts are those things we recognize with our hearts and our souls. The Constitution is about laws.
By contrast, the Declaration of Indepence is about “life, liberty adn the pursuit of happiness”– “inalienable rights” –which are very different from “legal rigths’ and which the authors of the Declaration believed were “bestowed by God.”
Since I’m not religous, I don’t believe these “inalienable rights” are bestowed by God. I believe that we bestow them on each other insfor as we
recognize each other as equal– simply by virtue of being human beings. Thus, the golden rule (which I place above any law) applies: Do unto others . . .
So I think that when you call health care a “right”–(in the sense of a legal right) you minimize how important it is.
Elusive as the distinction between rights and entitlements generally may seem, the very definition of the ‘health’ to which members of a civilization may have rights (or be entitled) strikes me as even more fugitive.
I hesitate to discourage Laura, but I believe Maggie has suggested the fundamental ambiguities we confront in discussing ‘health’ quite concisely with the examples she provided, whether or not the matter of rights ever enter our consideration.
Turning to the UN declaration cited, well-meant and ample use of modifiers like “adequate”, “essential”, “equitable”, and “appropriate”, to name just a few, indicate there’s a lot of work yet to do to produce a workable social definition of the ‘health’ all might one happy day assume as given.
It seems the consensus is that it is a moral obligation on society’s part. However, in that system there is an equal and just as noble moral obligation on the individual’s part to society which is: “you cannot over-utilize your -entitlement- of healthcare to the detriment of another.” This is not merely personal responsibility but something much more.
In my opinion the larger of the two issues is the personal obligation as opposed to the societal one; we have shown that compulsory monetary contribution to a societal entitlement is accepted and endorsed. However healthy habits refuse to be endorsed and obesity and subsequent CVD, diabetes etc… continue to increase. It’s a two way street and some have made the commitment towards it while most refuse. You cannot address the societal obligation without also addressing the personal one.
Additionally slavery by definition is the right to someone else’s labor. Not saying it wholly applies to this discussion but there seems to be some dispute about it.
kedent7 — and others who talk about personal responsibility–
Jon Shaffer is right– We have a huge body of reserach we shows that obesity, failure to excercise and other unhealthy behaviors are
directly tied to poverty. To mean this means that we have a moral obligation to provide these people with the healthcare they need–and the other things they need to live a healthy lifestyle. Safe playgrounds. Healthy school lunches (sirloin burgers rather than fatty hamburgers, fresh fruit and vegetables, chicken that has been broiled, not fried, etc.) Subsidized green-makers in their neighborhoods where fresh fruit and vegetables are inexpensive. Phys ed classes, gyms and playgrounds in inner city public schools.
A recent report showed that
rates of obesity have increased over the past year in 37 states. And “the report notes, the relationship between poverty and obesity rates. It found that seven of the 10 states with the highest obesity rates are also among the 10 states with the highest poverty rates”
In the US 38 percent of children live in households defined as poor (a family of three living on less than $16,000 a year) o near poor (a family of three living on less than $32,000). Children in poor families are nearly 5 times are likely to be in poor health when compared to kids in affluent families. Children in “near poor” famlies are nearly 3 times as likely to be in poor health.
OFten they are obsee
They eat food high in calories and low in nutrition because nutrious foods are far more expensive and often unavilable in ghetto grocery stores.
School lunches in public shcools in poor areas are high-carb, high-fat and low in nutrition. Many of their schools have no playground or gym and no phys ed. There are no safe playgrounds in the neighborhood.
Even in households where parents try to set a good example by not smoking and by exercising, that doesn’t help the kids much: 34 percent of children living in poor households where the parents exhibit healthy behaviors are in suboptimal health–often they are obeses. Often they suffer from respiratory diseases (due to the enviroment compounded by the stress of being poor, ant this makes exercise that much more difficult.)
By contrast, in affluent household where parents smoke and never exercise, only 10 percent of kids are in poor health.
Much of the obesity and other behaviors that harm health (self-medicating with alcohol or drugs to deal with the stress of being poor and having little control over your life) are concentrated in these households.
This isnt’ about taking “personal responsiblilty” for your health. Most of these people don’t have a choice: their poverty and circumstances makes it all but impossible to adopt a healthy lifestyle for themselves or theirr children. They can’t afford to enroll their kids at the Y, they can’t afford to buy fresh fish, strawberries and fresh
vegetables. They fry food because that’s a good way to provide enough calories so that their children don’t feel hungry (but they are malnourished.)
Rather than talkign about their “right” to good health we should be tgalking about our moral responsibility to
make sure that they have access to what they need.
Maggie:
To absolve any segment of a population from culpability is a very dangerous idea.
However, I agree that a generous number of those families are bereft of substantial options. I agree with you about providing adequate nutritional guidelines, provision of parks, health classes etc… These are the type of things that need to be engendered to broaden choices. Honestly these are what should be addressed at this juncture; not socialized medicine.
Experts unanimously agree that the prohibitive cost of health insurance is rooted in overconsumption; the law of supply and demand still rule – increase the demand and you will see increasing price/costs for procedures which leads to higher premiums. Universal healthcare will bankrupt our future even moreso than it already is IF we do it without provisions for assuring an initially “healthy” or health-educated population that will not go to the doctor for every cold or sniffle. Personal responsibility for your own understanding of how the system works will lower premiums.
We cannot enter into a universal program with a mindset that healthcare is free and available whenever we want it. We cannot look at it as an inalienable right. That is doomed to failure. This is a societal AND personal responsibility.
People must take care of themselves on a basic level; obesity for instance is so preventable (yes there are exceptions, I’m talking about 99% of the cases) it’s frankly laughable that its a national “epidemic”. We have to also know better and ask ourselves “how much will this cost the people that are supplying it for me.”
We have to empower not enable. I would much rather provide for someone a crutch than a wheelchair.
Maggie,
While I appreciate your points about the lack of reasonably priced healthy food alternatives, playgrounds, and other safe places to exercise for the poor, I think the incidence of obesity has been increasing across the income spectrum for many years.
In the case of poor children, I think many of their mothers lacked any sense of personal responsibility when they dropped out of high school, got pregnant and had one or more children out of wedlock often while still teenagers and with no man in sight to help raise and support the kids. While you probably have some good data on this, I believe the percentage of children born out of wedlock among the poor is far higher now than 40 or 50 years ago. I can remember when I was in high school, at least among the middle and upper middle class, there was such a stigma associated with getting pregnant out of wedlock that families literally often moved out of the area. If many of these poor mothers finished high school instead and waited until they got married to have kids, they (and their kids) wouldn’t be poor today.
No less an intellect than the late Senator Daniel Patrick Moynihan once wrote that the defining issue in our society is not race, it’s class. If Senator Obama becomes President on November 4th, he will be in a unique position to offer the underclass some straight talk about personal responsibility and I hope he does so.
Thank you, Maggie, for initiating and maintaining this very interesting discussion. The range of responses has explored many facets of this issue and highlighted common fears.
I posted the comment about the UN Declaration of Human Rights and I am glad that this has been discussed thoroughly.
It seems that many people have a fear of calling something a “right” and extend this concept to an “entitlement”; predicting a wide range of untoward consequences. To get around this problem, many think it better to call it a “moral responsibility” which they feel is at the same time stronger in the sense of obligation and weaker in the legal sense.
I’m glad to see that you have explored this further in your blog posting of 10 Oct on Alternet.org. However, I don’t think that we should back away from calling health a right. I came across an interesting book, Educating for Human Rights and Global Citizenship SUNY Press, 2008 (parts available on Google book search) that explores the original 1948 Declaration and the evolution of the term ‘rights’ (and also ‘entitlements) through four generations. The discussion explores many of the points raised here by various posters. The entire set of essays is of course too long to post here but I recommend it.
I do not think we should fear calling health a right. This may have some uncomfortable consequences but resolving these should be a beneficial exercise for all of us. I think all of us should be extremely uncomfortable about the primitive health care system in the US which fails to treat many people, provides obscene profits for a few, and leaves the US at the bottom of ‘developed’ countries in most of the common measures of health.
“I can remember when I was in high school, at least among the middle and upper middle class, there was such a stigma associated with getting pregnant out of wedlock that families literally often moved out of the area.
Well Barry, it seems now with Sara Palin, for not only herself but her daughter, that out of wedlock pregnancy is a sign of personal strength and requires understanding and support. Also used to be that the little bastards of out of wedlock marriages were also shunned by the community – that’ll teach’em. And just where did you expect the “families” of poor people to move to, and with what means if they had shame? Maybe we could start teaching that using a condom is better than pregnancy, but the religious right prefer ignorance over solutions.
This all gets down to the poor (especially the black ones in this country) having a realistic understanding that staying in school and doing what the more advantaged famlies do, will get them success. All they see around them is failure. Here in NC a recent DOT investigation found wide spread racism kept black construction firms from getting contracts. We also had racism here play a large part in which farmers got federal loans through the local (white good ole boy) loan agent. There has been a systematic effort to keep people down, not help them up. As we’ve seen from history in this country the poor don’t have the means or connections to succeed on a large scale, and even have additional barriers thrown in front of them. In New Orleans for example billions of dollars of tax concessions have been given to large corporations at the expense of local education. America has created a huge self-sustaining underbelly of poor that just saying, “personal responsibility” is not going to solve, although that approach usually is code for, “don’t raise my taxes”. I also get a kick out of the number of successful kids I’ve talked to who’ve inherited daddy’s business or carried on the family profession and talk about how it’s all about personal responsibility.
“Experts unanimously agree that the prohibitive cost of health insurance is rooted in overconsumption”
No, kdent7, it’s the high prices. Do you really believe that it’s the colds and sniffles that drive healthcare costs?
Peter, kident, Mark and Barry,
Thanks for your comments.
First of all, three factors drive the high cost of care in the U.S.
1) Prices- Peter is right. We pay signfiicantly more for drugs and devices than any other oountry in the world. (In other countries the govt negotiates for lower prices. here, we essentially pay whatever drugmakers and devicemakers demand.– which is why we pay so much more for exactly the same drugs and devices.
We also pay our doctors significantly more– even after adjusting for cost of living. Of course our doctors graduate from med school with huge loans– other countries subsidize the cost of med school. But our best-paid doctors (earning, say, $700,000 and up, are , arguably over-paid–as are the CEOs of our hospitals– earning !.5 million, 2 million etc., even at “non profit” hospitals.
Finally, we pay far more for a hospital room. This is in part becaues our hospitals invest millions in cosmetic, hotel-like amentities–and because, as they compete for well-heeled patients, our hospitals invest in very expensive redundant technology. Four hospitals within a 3 mile radius will have the saem cutting edge technology. In other countires, where hospitals collaborate (rather than competing) one medical center would have that technology; another medical center woudl specialize in something else.
When four hospitals have the newest diagnostic imaging equipement, the only way to pay for it is to use it–which is why patients receive so many unnecessary tests.
2) We also are quick to adopt the newest technologies–even when there is no evidence that they are better than the less expensive technologies that we already have. The FDA only requires a manufacturer to test his new product against a palcebo–proviing it is better than nothing.
3) Finally, supply drives demand.
Kident– I know that is counterintuitive. In most sectors of the economy, demand drives supply: companies produce what consumers are buying, But when it comes to healthcare, the seller (the doctor or the hospital) tells the patient what he needs.
Typically, a patient doesn’t ask for another round of chemo–he is told “this is what we are going to do. This is the protocol.” His doctor tells him what drugs he needs to take. A doctor tells him when he needs to go into the hospital. A surgeon tells him when he needs surgery. The hospital tells him that he needs to be in an ICU.
Sure, some paitents “demand” an MRI– but Peter is right- it’s the big-ticket items that drive our $2.2 trillion health care bill–not the people who go to the doctor when they have a cold. Or want an MRI when they sprain their ankle. High-tech medicine drives runaway health care inflation.
The proof that supply drives demand? Researchers at Dartmouth have done more than two decades of research showing that Medicare spends twice as much, pre patient, in areas where there are more hospitals and
more specialists–this is after adjusting for differences in local prices, race, age and the overall health of the population. I’ve written about this researach here–
http://74.125.45.104/search?q=cache:tGsu3EsCqwAJ:www.healthbeatblog.org/2008/02/a-blueprint-for.html+Dartmouth+and+Wennberg+and+Medicare+and+map&hl=en&ct=clnk&cd=1&gl=us
I think you might find it interesting. While many uninsured and underinsured people receive far too little care, other well-insured people (including many on Medicare) are overtreated–this is not only expensive, it is hazardous to their health.
In those regions where Medicare spends twice is much, outcomes are not better, often they are worse.
Kident– You write: “I agree with you about providing adequate nutritional guidelines, provision of parks, health classes etc… ”
But here is what we are actually doing: (from a very recent U.S. New & World Rerpot article):
“While all 50 states and the District of Columbia have passed laws related to physical education and/or physical activity in schools, ONLY THIRTEEN states include language to enforce the laws. Of these states, ONLYR FOUR have sanctions or penalties if the laws are not implemented.
“While the Dietary Guidelines for Americans were updated in 2005, the U.S. Department of Agriculture school meal program HAS YET TO ASOPT THE RECOMMENDATIONS.
“Eighteen states have enacted laws requiring school meals to exceed USDA nutrition standards. But,ONLY SEVEN s of these laws have specific enforcement provisions, and ONLY TWWO state laws include sanctions if its requirements aren’t met.
“TEN STATES do not include specific coverage for nutrition assessment and counseling for obese or overweight children in THEIR MEDICAID PROGRAMS. TWENTY STATES explicitly do not cover nutritional assessment and consultation for obese adults under Medicaid.
Why aren’t we doing what we know we shoudl be doing in terms of phys ed & school lunches? Why do we deny poor children and poor adults help with obesity under Medicaid?
Peter has the answer:
” America has created a huge self-sustaining underbelly of poor that just saying, ‘personal responsibility’ is not going to solve, although that approach usually is code for, ‘don’t raise my taxes;’”.
Exactly. We are simply unwilling to pay the taxes we would need to pay to provide physical education classes and nutritious school lunches. So we feed the kids carbs, fats and sodas– and then blame them for being obese becuase their irresponsbile “mothers had them out wedlock.” (Barry, I’m not even going to comment on your argument.)
.
We are unwilling to pay the taxes needed to build paygrounds and gyms in inner city schools. Or to pay full-time phys ed teachers.
In other developed countires, taxpayers spend much more on social programs, and the percent of children living in poverty is much, much lower. See the chart under the sub-headline “Poverty and Spending on Social Programs in this post: http://74.125.45.104/search?q=cache:PX_3b79wi8UJ:www.healthbeatblog.org/2008/08/poverty-health.html+poverty&hl=en&ct=clnk&cd=1&gl=us
Inevitably, people who talk about how the poor should take more “personal responsibility” are libertarians and conservatives who are simply unwilling to pay the taxes we would need to pay to create the oppotunites for poor people to live in a healthy environment, receive a good education and have access to healthcare. (By paying doctors who take Medicaid patients 30% less than we pay doctors to treat Medicare patients, we ensure that very few doctors will take Medicaid patients. This means they have access to the doctors who no one else wants to go to–and residents who man the Medicaid clincis in many academic medical centers. These residents are, by defintioing, less well-trained and less experienced than the doctors the rest of us see.
Mark– thanks for your comment. I prefer the language of a society’s moral responsiblity over the language of individual rights because I think it is terribly important that people in this country begin to think collectively, rather than individually.
As I often say, France has a very good health care system because the French believe that nothing is too good for another Frenchman. Unfortunately, we in the U.S. do not feel that way about each other.
Individuals should not have to demand healthcare as a right; we as a society should be willing to freely provoide healthcare for all because we recognize we recognize each other as equals–and as humans. As I’ve said, the underlying rule is this: “Do unto others as you would have them do unto you.”
As a civilized society, we must subscribe to that rule. If we don’t, no amount of laws guaranteeing rights will do us any good. Look at the laws above that we are not enforcing.
Peter,
“No, kdent7, it’s the high prices. Do you really believe that it’s the colds and sniffles that drive healthcare costs?”
How do you think costs are determined? Cost is reactive, it does not merely manifest. Yes there are baseline procedural determinations of cost, yet costs keep going up anyway. Despite what you think insurance companies are not building Taj Mahal’s and flux-capacitors with the billions of innocents’ dollars; they have to fulfill the cost of care and due to this premiums rise as cost is rising. I am not saying they are victims however. With that out of the way you need to look at what causes cost to increase.
Maggie,
The average physician salary however is not nearly 700k. Maybe a 1/6 of that. Coupled with 200k student loans I have trouble seeing an issue with it. The bottleneck of care supply is regulation of health education procedures; nurses are able to perform far more complex tasks than currently allowed, and med schools need to expand education beyond academic elites.
I completely agree as far as drug cost etc. That is out-of-control and needs to be addressed. As to how; frankly I’m not sure. Additionally I agree about new technology that is just unneeded bloat and is not any more effective than current practical methods. These need to be “trialed” and efficaciousness proven. It’s comparable to lobbying in congress in this system. These machines get sold somehow and hospitals need to be responsible in more thoroughly addressing their benefit.
However part of what you do not address is liability on doctors part. Why do all these redundant tests get pushed? In part due to the fact they are scared of getting sued. They need to show that they provided “adequate” appropriate care so they are not to blame if something goes wrong. Healthcare is a very inexact science; to blame a professional for an unforeseen mishap (which is quite routine) to the tune of hundreds of thousands of dollars is reckless to both the physician and the hospital. Why demonize those that are providing care in this manner? Liability laws/damages need drastic reform to keep costs under control so not as many tests are needed. You cannot just say that they dictate excess care and not address why they are doing so.
Established hospitals quite frankly cannot provide communal recovery and treatment rooms. I understand what you are getting at with this but the public would not accept a situation like what Japan provides. We have become rather…plush; and for current hospitals that ship has probably sailed. However new facilities under a somewhat different more innovative guise of care could do this successfully.
Thinking critically allows us to trace some general cause and effect. I’ve talked to so many people that have the stance of “well I’ve hit my deductible, might as well try to hit my co-insurance too and get everything checked out and taken care of” to the tune of some 5k-10k$ run on health expenses that may have not even been needed or beneficial! And the doctors go along with it?!?! We need fundamental education on the system for both parties. We have a public-thought process that says “any and all care is good and quality care.” That is blatantly false. How often have you asked a doctor what a test will cost? It’s a basic mechanism of economics that is compounded due to health consumers and physicians being protected from the reality of the dollars that consumption entails.
It is unacceptable. It is an egregiously irresponsible act that is driving a system to failure. So yes, overconsumption is the ROOT of the high prices and that has been agreed upon across the board. So in effect you are right, its high price and over prescription of services. All parties are to blame overall. And sadly this makes coverage prohibitively expensive for those with less.
There are more than a few ways of dealing with that: less moral hazard and more personal accountability, tax sheltered HSA’s (don’t hate me please) and more importantly training more health related professionals/nurses/doctors etc would increase supply of care… I won’t get into that though because that has its own set of hurdles and we need a short term break right now as opposed to a long term one.
I think you misread my comment about social programs. I did not say they were adequate as is. They need to be improved and subsidized such that they do have a positive effect as opposed to what is going on now.
I argue those needs should be met before universal healthcare due to the fact that if a universal system is implemented at this time it will mortgage our country even moreso than it already is as more and more people will need care on a system that is already overused and short-staffed. What that means is higher and higher cost as I explained above. Look no further than Massachusett’s as a prime example of utilizing a universal coverage system at a possibly inappropriate juncture in time. Wonder why they are seeking a federal bailout for their state eh?
Ultimately it comes down to this. Can we promote societal AND PERSONAL responsibility concomittantly without giving someone a free lunch (Medicaid excluded) yet providing an affordable lunch for everyone.
Despite what you may think I am coming to the belief that a two-tiered system that promotes realistic care while still allowing some of the more health-conscious among us to obtain personally funded coverage would be the most successful and equal system for this country.
kdent7, Insurance reacts to cost, it doesn’t control it, or at least wants to control it in healthcare. Unless of course you think denial of coverage and retroactive cancellation of coverage are legitimate ways to control costs.
“two-tiered” does not equate to “most successful and equal”. Two-tiered systems starve the publically financied one while the private one gets the best care. As well, the upper tier will draw the healthy and weathly, so the lower tier pool will have the sickest and most costly. A system that recognizes, that for healthcare, we’re all in the same boat, is the one that works the best. Unless of course, if you’re employed by the insurance industy.
In all these discussions, there seems to be a great divide (that kdent actually tried to bridge in his last post): it is either social responsibility or governmental intervention that should do the trick.
I worked in health care both in the US and in Germany (and also spent 8 mos. of training in France), so I do have have some perspective.
The fact is that with every entitlement program, there is some degree of abuse. And there are a lot of folks in the US (maybe even more so than in the European countries that I know) who avoid personal responsibility and/or game the system to their (unfair) advantage.
Does it mean that there should be no moral obligation to healthcare (or no right – I really find this question a rather semantic one … although it is important as the framework of the discussion needs to be set appropriately)? Of course not. One can (and should) introduce universal healthcare in the US, and at the same time address waste, abuse and poor attitude (e.g. by having different copays for smokers and/or the obese). And yes, I think that there are cultural factors in play that should be adressed explicitely. These efforts should include teenage pregnancies out of wedlock as well as middle class parents raising their kids on TV, videogames and sugared fruit juices. Just ointing to personal responsibility will not do.
I believe that a solid majority in the US will not let bodies pile up in front of the ER door, and ergo there is support for universal health care. What has to happen next is that the medical community becomes more united about the best ways to address the problem. If I am not mistaken, even the AMA seems to be moving into a better direction (compared to a decade ago).
As a side note to kdent, MM has not claimed that 700 K is an average physician income. There are, for sure, very many doctors who are north of 250 K (and quite a few who are north of 500 K), and I would not be surprised if the average physician salary is around there (maybe MM has the exact fugure and could tell us?). That’s for sure part of the problem, but I read a statistic that a drastic paycut for physicians would only result in 3 % savings or so.
kident7–
I don’t know where you get your information, butno, the average income for a physician in the U.S. is not $115,000 here are the real figure from tables published in 2007 by Merritt, Hawkins & Associates, a national health care search and consulting firm that specializes in recruiting physicians.
And note these figures do not include bonues malpractice insurance or health benefits–which are usually paid by the employer.
Radiology – Radiology
2006/07 average $380,000 high end $500,000
Orthopedic Surgery
2006/07 average– $413,000 high end–$650,000
Cardiology
2006/07 average– $391,000 high end $500,000
OB/GYN
2006/07 average $247,000 high end $345,000
Neurosurgeons- average $527,000 high end $850,000
Urology
2006/07 averfage $400,000 high end $500,000
Even the lowest paid physicians ( pediatricans and family docs ) average $160 to $200 and $170 to $250. Interist range from an average of $175,000 to $275,000.
These physicians at the low end need a hike in wages–particularly starting salaries because they do have enormous loans. Fees for certain services at the high end need to be cut. Reserach shows that when certain provedures are too lucrative we do way too many of them and patients are harmed.
As for your notion that overconsumption drives soaring health care costs, I don’t know what to tell you. We have decades of reserach showing that this is the case–dozens of articles in journals like Health Affairs, JAMA, NEJM.
But clearly you have little respect for facts, evidence, or research.
As for bringing down drug device prices: it’s quite simple, we let the government negotiate for lower prices the way every other govt in the developed world does. As for prooving effectiveness– we demand unbaised head-to-head comparisons of new treatments, comparing them to existing treatments, and then raise co-pays on less effective treatments while reimbursing doctors more or porvide more effective treatments.
On a two-tier system: how will you feel when your children, through no fault of their own, wind up on the second tier? (A bad break, a job loss, a very sick child, or maybe just an economic meltdown like the one wa are facing. A great many previously employed upper-middle class people will find themselves unemployed, and sliding, all too quickly into the middle-class, perhaps the lower-middle-class depending on how much debt they have accumulated, the size of their mortgage, and their chances of getting another job. .
Please see Peter’s comment.
Peter –
Thanks. As you say, a two-tier system is ultimately bad for all of us.
And insurers gave up trying to control costs after the backlash against managed care in the late 1990s. Now they’re just passing higher costs along in the form of higher premiums. And, with the exception of Medicare Advantage, they are not making fat profits. They’re on the ropes–high prices for healthcare, and the fact that many employers are backing out are hurting them too.
The UNHOLY ALLIANCE between HOSPITALS and HEALTH INSURANCE Companies is the reason for this national crisis.
When the non-profit hospital GOUGES the uninsured for 6000% of the actual cost of care, (and then proudly announces how much “charity” care they have given – after first aggressively trying to collect this obscene amount from the patient) it FORCES us to buy insurance against “the high cost of medical care.”
Doctors make around $32 per visit by most health insurers/Medicare. Yet the EOB the insurance company gives you says the “usual charge” is $90! Again, why isn’t this fraud? The insurance company uses this fictitious charge as leverage to EXTORT you into buying health insurance. If we are being honest, we aren’t buying insurance at all, we are buying a negotiated lower billing rate.
Most Americans can easily afford a $32 visit, just as we afford haircuts, lunch, or auto repair. We cannot afford Hospital and Insurance Fraud.
This discussion is flawed when we use the terms dictated to us by those in control of the current system. The “health care crisis” the “high cost of medical care” are based on fraud, extortion, and fear generated by our hospital system’s obscene exaggeration of the cost of care, and the happy collaboration of the health insurance industry.
Caught in the middle are doctors and patients.
A national health insurance plan isn’t the answer. The answer is TRUTH and TRANSPARENCY in hospital billing.
The answer is affordable government-owned clinics which pay doctors a fair salary and provide immunity from malpractice claims, and provide a safety net for the poor (and let’s be honest, government is already in the business of healthcare).
We should avoid the trap of using the extremes (those wealthy enough to afford the best quality care and those dysfunctional enough to wreck their health and finances with abusive lifestyles) as examples for our efforts to “fix” this system, and work to provide a safety net
Maggie,
Could you provide a link to your figures? I just went on the Merritt, Hawkins & Associates websitehttp://www.merritthawkins.com/compensation-surveys.aspx
and did not find the numbers that you posted. Not to be misunderstood, I think they are accurate (they certainly do proof your point), but they are probably a little skewed:
-Merritt, Hawkins & Associates is a private recruiting firm and to my knowledge is rarely involved in recruitment for academic centers and VAs
-you listed mostly the high earning specialties (probably to prove your 700 K claim), but left out “nonprocedural” specialties (e.g. Neurology, Psychiatry, Rheumatology, Endocrinology etc.
Again, you are definitely much, much closer to reality than kdent, but these figures look slightly skewed. I am interested in the source anyways.
rbar:
Happy to give you the link: http://www.merritthawkins.com/pdf/2007_Review_of_Physician_and_CRNA_Recruiting_Incentives.pdf
When I just went back to my original post,
http://www.healthbeatblog.org/2008/01/health-care-spe.html
and click/controlled on it, it came up.
I actually didn’t skew the specialties– the only one you list that I didn’t include is psychiatrists –$186,000 to $230,000– still much more than the $115,00 that a reader suggested was the average. income for physicians
The aother specialists you list are not included. (probably not a lot of recruiting in those areas.)
I also didn’t include the low end salaries– in part because those tend to be salaries for foreign-educated doctors and doctors who are just starting out. (As I said, I think that starting salaires should be hirer, particularly for those practing cognitive medicine, so that they can pay off the loans. But I’m much rather see us subsidize medical education, as in other countires.
Also I didn’t try to factor in the benefits that doctors receive –including malpractice insurance paid by employer (paid by the majority) plus health benefits and large signing bonuses (very common. These items should be added to these “base, guaranteed” salaries.
But here is the important point– as a percentage of the dollars that we, as a nation, now spend on physician care, the specialists account for the largest share.
So that is where we should look for possible savings.
Peter,
kdent7, Insurance reacts to cost, it doesn’t control it, or at least wants to control it in healthcare. Unless of course you think denial of coverage and retroactive cancellation of coverage are legitimate ways to control costs.
I have no idea where in my post you got the notion that I said insurance controls cost, you may want to reread it. I specifically stated that cost in excess of baseline is reactive to demand and therefore insurance premiums react to cost, hence the propagation in premiums. Please don’t argue some point for the sake of arguing.
Maggie,
Ad hominem seems rather unbecoming given your previous helpful postings. I rather admire your clarity in the article, it was well written, informative, and I enjoy the stick-to-itiveness to your cause. I suppose my foray into providing a little devil’s advocate has fallen on the ears of the myopic however. I actually have the utmost respect for studies and research as they show quantitative advancement in understanding.
There are however some very serious issues with some of your statements in what appears to be a rather disengenuous attempt to solely empower your mindset instead of your reader. You address merely one end of the spectrum:
“But our best-paid doctors (earning, say, $700,000 and up, are , arguably over-paid–as are the CEOs of our hospitals– earning !.5 million, 2 million etc., even at “non profit” hospitals.”
This is intentionally misleading on your part and you should be able to recognize that, given you made no mention of “standard” physicians (thank you for your clarification rbar). I suppoe I could say “some bloggers make up to 250k!!!” Now what did I prove…{pause}…tumbleweed…crickets…{sun consumes planet}…obviously nothing.
Lets settle it and say…”its somewhere in the middle”, which it is. I shot from the hip, you misled; both fallacy.
“As for your notion that overconsumption drives soaring health care costs, I don’t know what to tell you. We have decades of reserach showing that this is the case–dozens of articles in journals like Health Affairs, JAMA, NEJM.
I have trouble following your statement here. You’re saying I’m correct?
Before you look at this table it says 2001. Yes I know this.
Settings, 2001
Physician Field Salary
Primary Care Physicians
Family practitioner $129,400
General practitioner $135,600
Internist $131,200
Pediatrician $128,700
Specialists
Allergist $160,300
Anesthesiologist $233,400
Cardiologist $251,700
Dermatologist $160,800
Ear/nose/throat surgeon $199,200
Gastroenterologist $202,200
General surgeon $206,100
Neurologist $163,200
Obstetrician/gynecologist $204,400
Oncologist $180,800
Ophthalmologist $222,600
Orthopedic surgeon $289,000
Pathologist $189,000
Psychiatrist $139,600
Pulmonologist $142,900
Radiologist $186,600
Urgent visit/emergency physician $172,300
Urology $227,200
*Survey includes base salaries, net income or hospital guarantees minus expenses
U.S. Physician Salaries – Ongoing Salary Survey
2001-2006
*Survey includes base salaries, net income or hospital guarantees minus expenses
The following survey data also lists maximums of pay which are all over the place and MANY in excess of even your statements, so feel free to look those up yourself and stoke your burning desire for healthcare reform by focusing on the fringe population of physicians and becry “Repent loathful sinners!” (I’m joking with this.)
June, 2003 – 2006
Type
yr1-2 >3
Allergy/Immunology
158 221
Ambulatory
80 112
Anesthesiology: Peds
283 311
Anesthesiology: General
207 275
Anesthesiology: Pain Mngmnt
315 370
Cardiology – Invasive
258 395
Cardiology – Interventional
290 468
Cardiology – Noninvasive
268 403
Critical Care
187 215
Dermatology
195 308
Emergency
192 216
Endocrinology
171 187
FP (with OB)
182 204
FP (w/o OB)
161 135
FP – Sports Med
152 208
FP – Urgent Care
128 198
Gastro
265 349
Hematology/Oncology
181 245
Infectious Dis
154 178
Internal
154 176
Hospitalist
161 172
Pediatrics
139 168
Medical Oncology
198 257
Neonatal Med
826 310
Nephrology
191 269
Neurology
180 228
OB
211 261
Gynecology
159 213
Maternal/Fetal Med
286 322
Occupational Med
139 185
Opthalmology
138 314
Opthalmology Retina
280 469
Orthopedic Surg
256 342
ORS – Foot / Ankle
228 392
ORS – Hand / Upper Extrem
288 459
ORS – Spine
398 670
ORS – Sport
266 479
Otorhinolaryngology
194 311
Pathology
169 311
Pediatrics
135 175
Ped – Cardiology
145 282
Ped – Criticl Care
196 259
Ped – Hematology/Oncology
182 217
Ped – Neurology
175 189
Physiatry
169 244
Psychiatry – Child / Adolesc
158 189
Pulmonary Med + Critical Care
215 288
Radiation Oncology
241 385
Radiology
201 354
Rheumatology
179 229
Surgery – General
226 291
Surg – Cardiovascular
336 515
Surg – Neurological
354 541
Surg – Plastic
354 541
Surg – Vascular
270 329
Urology
261 358
In final, I was wrong; you filtered information. Both guilty thanks to the blessings of research eh.
Two-tier when done correctly allows the people with concern for their own being to pay more out-of-pocket to provide for themselves the kind of care they desire. Besides what possible reason would there be for people to employ private insurance if the socialized program is employed coherently? None…except for that little bug we should all value oh so very much: personal choice, or rather, liberty. I enjoy having it as should we all. The socialized program offers those without choice atm to get coverage, the second tier allows those who take an active role in their health (which not even you can argue that everyone does) to make decisions pertinent for themselves without buying into the system. Maybe that makes me a fringe…
At any rate I won’t post anymore on this discussion. Commence and thank you for the informative and previously productive banter
rbar,
Since you once worked in Germany, trained in France and are now in the U.S., I wonder if you could provide me (us) with some insight into the following topics:
1. Can you estimate the approximate difference in incomes between physicians in the U.S. vs. Germany and France – both specialists and primary care docs?
2. How would you characterize the difference between the aggressiveness and intensity of treatment patients generally receive in an inpatient hospital setting in the U.S. vs. Germany and France?
3. How do differences in the litigation environment (both real and perceived) impact on the amount and cost of defensive medicine practiced in the U.S. vs. Germany and France?
4. How would you describe the differences in cost and approach to end of life care (including the treatment of very premature infants) in the U.S. vs. Germany and France?
5. Do you have any feel for the differences in the cost of healthcare fraud in the U.S. vs. Germany and France?
6. Finally, how important a factor is the higher cost of drugs and medical devices in the U.S. vs. Germany and France? As a follow-up, are there significant differences in the cost of specialty drugs from country to country for which there are no generic substitutes? Are other countries simply more willing to refuse to pay for specialty drugs deemed too expensive on a QALY metric basis?
kdent 7
Thanks for some kind words– and I’ll take you at your word that you are interested in research . .
So I’d urge you to go to http://www.dartmouthatlas.org to read about supply driving demand. Dartmouth has more than two decades of research on this–their rersearch is now accepted by both the cognoscenti of medicine, medical journals, and mainstream media
When I wrote : “As for your notion that overconsumption drives soaring health care costs, I don’t know what to tell you. We have decades of reserach showing that this is [NOT} the case–dozens of articles in journals like Health Affairs, JAMA, NEJM– I left out the NOT. I’m sorry; it was a typo.
And when I wrote that our “Best-Paid” dcotors earn over $700,000″– that is quite accurate.