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Is Health Care a Right?

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.

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  1. I was suggested this website by means of my cousin. I’m not certain whether or not this submit is written via him as no one else know such distinctive about my difficulty. You are amazing! Thanks!

  2. Hopi, please recall that Medicare is all but bankrupt. Also, Social Security is about to go belly-up. Every “great social experiment” placed before congress has been, sadly, just another treasure trove for them to loot. They express good intent at the start, but dig into the funds and use them on their pet projects elsewhere, depleating funds intended for other more altruistic activities. What would make anyone believe that congress would not do exactly the same thing with healthcare taxes and funds? The best measure of how some entity will be have tomorrow is how it behaved yesterday.
    Congress will not change. Congress will loot the funds put before it to gain power and more funds for itself. And while many would like to believe that health care is a “right,” I am afraid it will be an unfunded right in time. Additionally, if it is a “right,” how is it possible that a right can be managed by a committee and multiple government bureaucracies? If goverment manages a “right,” it is then no longer a right but is a service or good.

  3. Wow, as I understand it then, basically everything in the world is a right! Everyone gets everything that may help society. And I am sure almost anyone can make a case to justify almost any good, service, action, or thought as having some tiny bit of societal benefit to someone.

  4. The semantics of “rights” is not the correct basis for the discussion of healthcare. When government provides “free” education, they do so to a limited extent so as to benefit the society as a whole. The same is true of many of the public goods that the government provides. When the government can come to a decision on what is the level of government provided healthcare that will benefit the society as a whole, we shall have such a system. I believe this was done under LBJ for those who survive past the age of 65, perhaps as an inducement for all of society to do whatever is necessary to survive past 65 if they do indeed want a government subsidized healthcare.

  5. What an interesting thread. As someone married to a Brit, I’m here to tell you that all of our friends and family (in the UK and elsewhere where they have universal health care) would NOT trade their systems for ours (at least nine out of ten of the ones I’ve talked to/heard about, etc. would not.) The UK system is actually the one that I think is the only likely contender for a system in the US…. e.g. they DO still have “private insurance” and private care, for those that don’t wish to use the NHS for whatever reason.
    So, far as I’m concerned, the docs that don’t want to work in some kind of future UHC in the US can set up private practice (or concierge practice) and this method would sustain a (small) margin of those currently employed by the (sigh) Health insurance industry.
    Yes, we have 300 million people we’re talking about vs. the 60 million or so in the UK, but still, it can be and needs to be done. (incidentally the UK has had universal health care available to all her citizens for very roughly at LEAST 60 years.)
    However it won’t happen until or unless there is enough public will building and public clamor to insist that it MUST happen. (for those of you, that is, who want to see UHC come about here.)
    Personally, I think a lot more people’s parents, and children, and siblings, and friends will have to die (possibly including me, who just lost her job and–therefore–my health insurance) before a damn thing is done about it.
    I don’t want to be treated by any nurse or doctor who feels they are enslaved to do so. (lots of ’em won’t!) Let those people go into/stay in private practice.
    as a side note, anyone who might read this (on this very oldish thread) may be slightly interested to know that none of my extended family or friends will set FOOT in the USA for even a ten day visit without purchasing (very expensive) travel health insurance. Oh yeah, and they ALL think that our LACK of a system of Universal Health Care is a clear indicator that we are an extremely uncivilized bunch of folks.
    personally I’m inclined to agree, (about our uncivilized general state of being) though nobody promised me a freakin’ rose garden. I’m 41 years old, have worked full time since age 15, have a college degree, have never had a cent of public money… and had the misfortune to have uterine cancer at 34. The only reason I was able to avoid bankruptcy was that my mother was in a position to give me a loan.
    A lot of the folks posting seem to figure that, well, should it turn out that the cancer has spread, that they should just let me die. Thanks a million. Some day some of you fine people will be walking in my moccasins… or watch your sister or mother or best friend in that situation.
    Charity in the history of mankind, to my knowledge, has NEVER been enough to cover even the basic needs of people. (food, water, shelter, health care.) It isn’t now and I don’t think it ever has been.
    I’m NOT so sure that a segment of our population wouldn’t be fine with bodies piling up in front of the ER.
    The “I’ve got mine, so to hell with you people” brigade is alive and well.
    Ayn Rand had some interesting points, but mostly, she was WRONG. Funny thing is, everybody fancies themselves one of the productive ones that carries the world on their shoulders. Most are wrong about that, too.

  6. This is great! This entire thread is wonderfully entertaining. Those of you who think people are enslaved when compelled provide care are correct. Those of you who think healthcare is a right are nuts. Those of you who think government can do anything better than the private sector are really nuts.
    Me? I am a 26 year ER doc. Same hospital and same ER. I am not gifted with time or prose, so just a list of inescapable truths:
    1. No one has defined “healthcare”. I read about “basic care”, but no one has defined what they wish to provide. This leaves everyone free to hear what they want and everyone free to imply what they want, which leaves everyone happy but totally wrong.
    2. Despite all the healthcare in the world, everybody DIES. This inconvenient truth is why healthcare spending is good for the economy but not necessarily money well spent.
    3. The salaries quoted from some servey are BS. The only doctors who answer those surveys are at the bottom of the salary ladder.
    4. Medicare and Medicaid solved political problems, not healthcare problems.
    5. There are four ways to pay for healthcare, not three. They are: Self pay. Third party payor. Government. And STEAL it. In my world one third is stolen by extortion and intimidation by both gov and third party. One third is just plain stolen. One third is paid for by all of the culprits.
    6. No one can make you sicker quicker than a doctor. You go in feeling fine and leave with scheduled tests, three prescriptions and bags of guilt and worry over your previously ignored but inescapable mortality.
    7. The malpractice “crisis” is a sideshow; if I could collect my fee from all players and payors, I could afford any insurance premium they can charge me. I could also have lower fees, if everyone paid.
    8. A right should not cost anyone anything. A right is not an entitlement. “Entitled” means eligible or qualified, not guaranteed and not necessarily free of charge.
    9. Healthcare, by any definition, is a commodoty, which is to say it is limited in its availability and it’s value determined by the number of dollars pursuing the available supply.
    10. I am paid by the hour by my own corporation, but my productivity ultimately determines how much money is available for distribution. Part of my compensation is based on productivity. I am not paid by the hospital. I am not EMS or the police. I am a physician.
    11. Money was invented to determine who could have what.
    12. We already have a demo project for universal healthcare in this country. It is the Department of Defense and the Veteran’s Administration. No need to make this model nationwide.
    13. It’s been 16 years since Hillarycare, and apparently none of the uninsured have died without healthcare. The number obviously just keeps getting bigger, so they must be doing ok without it.
    14. It will be too difficult to define healthcare, but we can probable judge situations that are not healthcare and just stop providing funding for those situations. Let’s first discuss death and dying. America does death very badly. This discussion is not about assisted suicide, and it is not about euthenasia. Let’s just let old people be free to die. let’s free their families from guilt and from anger over nursing home care. Let’s let people have a chance for a better life after ill heath developes, but let’s let them be free to die of there continued flagrant failure to choose wisely.
    15. The cheapest healthcare is no healthcare.
    16. The patient must have a reason to not go to the doctor, if we are ever to cut costs. The insurance companies are trying to make that reason an ever-increasing co-pay. This is the only sensible way. But then people should not believe they are actually using their insurance for office visits. Everyone should just get major medical which should always include some part of the cost being paid by the patient.
    17. No amount of screening will cut the cost of care.
    18. Technology cannot make care cheaper. Slower, yes. Cheaper, no. Time is money.
    19. Better, Faster, Cheaper: Pick one.
    What I am saying is that government should not be in the healthcare business at all. People should make wise choices, but those choices should be made by the individual, not by Hillary or Barack or John (Edwards) or by me or by you. An enlightened society may wish to fund healthcare for the less fortunate in the country, but an enlightened society should not presume to know what value an individual puts on his own life with regard to either government or healthcare. An enlightened society should respect the rights of the individual to be free of unwanted government asistance So this discussion is in the looming shadow of the next political solution involving healthcare. It (ObamaCare) may solve a political problem, but it will undoubtedly screw up the delivery, availability, cost, and quality of healthcare.

  7. It should be a right, just like speech. I am able to speak the truth, but don’t have the right to demand that others pay for my microphone.

  8. When addressing the argument of universal health care as a right or privilege, I don’t know of an immediate solution other than changing the society’s internal values – basic mental foundation – about health care. It doesn’t matter what external improvements you make on a home, it will collapse if the foundation is not laid properly.
    A shift in spending priories for the U.S must occur. As of now, the U.S. economy is based on capitalistic views and competitive mind-sets…leading to the recent economic disintegration. Currently, you have a government bending backwards to keep corporations out of a financial crisis while having little concern for long term consequences and neglecting more important concerns like health care.
    Essentially, the problem needs to be addressed locally (community health needs, etc) and then nationally, by the significant policy makers, so to sustain ‘social solidarity.’ Thus, I believe in improving health care access by working at a local community level, for now, with an end goal of national health care.
    Why at a local level, specifically a state, city or county level? Relative to a national approach, the health concerns of smaller communities are easier to manage and budget requests are not as large, keeping in mind that there is adequate funding. Also, it’s more efficient for the federal government to provide adequate funding to states so they may budget, as they see fit, versus the Fed taking the sole responsibility to fund and implement a ‘national health insurance.’
    Is it more efficient to have the federal government provide funding to the states and allow them to implement their own state health care program? To help answer the questions, let’s look from a macro prospect and study the Canadian Federal Government, which allocates health funds to all its providences. These funds are known as provincial health funds and “on average, provinces spend about 39% of the national GDP on health care” versus the United States’ 16% (Congressional Office Budget). The provincial health funds are spent efficiently as the Canadian federal government shows “substantial [financial] support for health care.” I’m not advocating that we replicate Canada’s system, which works for a population ten times smaller than ours, but we must find an efficient means as they have to managing healthcare spending. A report by the Congressional Office shows inefficiency in U.S. health care spending, costing the US nearly $700 billion, or 5% of the GDP, each year (COB).
    Now that being said, the programs of local health coalitions (LHC) are a good example of working from a local level. Privately funded or state funded, LHC’s are able to provide free or affordable health services by implementing programs that meet the community’s need. After working with the Well Florida Coalition in Gainesville, Fl, I’ve noticed three significant advantages of local health coalitions. Firstly, community stakeholders (i.e., local health departments and citizens) can participate in expressing their needs through ‘needs based assessments,’ which allows for direct communication and transparency between stakeholders and the LHC. Second, funding is more efficiently utilized as it focuses towards the community’s specific health disparities. Lastly, when the local community is involved, they become more self-empowered as it becomes their responsibility, leading to a higher chance of program sustainability.
    I agree, that “social solidarity is a key to improving public health.” Universal Healthcare must be adequately funded, which is a challenge, yet it is essential as a social priority.

  9. Mr. Hansen offers an interesting comment which is skewed to what many would view as a very fatalistic approach. In the offered comments, basically, he says that death is predetermined at birth and apparently chooses to ignore that the vast majority of infirmities are acquired and not inherited. The costs of healthcare in the first two and last two years of life do consume an inordinate amount of the total healthcare dollar. Is his comment pointing out that these are “wasted” or ill spent and that those dollars should not be spent?
    Aside from that he offers four questions to be answered:
    1 – What is the definition of basic care?
    Unfortunately this is a part of the current problem. There is no current good definition of a basic healthcare coverage plan. There are a number of plans that offer numerous variations on the theme and attempt to pass of costs to the consumer. This question is the very first step in the development of a universal healthcare plan.
    2 – What should basic care cover?
    Any attempt to answer this question at this point would open the door to why not include this or that. I am not implying that such a discussion would not be beneficial but it would be premature until the definition is provided by an authoritative body.
    3 – What is the basic definition of “quality of care?”
    Quality of care is the current standard of care as accepted by the “experts” in the field. It means a minimum standard that includes the general experience of results and performance.
    4 – What is the basic definition of “quality of life?”
    This is a very difficult question to answer since it encompasses an individual’s expectation of life from a variety of aspects. I recall what my step dad said when asked this question and his response was that if in the course of care someone could offer him one more minute then he wanted that because then it would be possible that someone would have the permanent answer to address his problem. Christopher Reeves is another example, once paralyzed his life was different but would anyone suggests that he did not consider what remained a quality of life?
    Answering the above questions does not aid in defining the basic issue of this blog. I will restate my position that healthcare is an individual right for which the individual has the privilege to pay. Make that privilege the individual’s sole responsibility we can then begin to address the out-of-control costly system that currently exists.

  10. Looking from the outside in, I find the healthcare industry totally wrapped around its axles. Medicare has been termed as an entitlement program, which begs the question “Why are individuals paying into a system they do not have access to until they are 65?” granted, there is a small percentage of individuals who get Medicare who have not paid into it. Next, with the shortages of providers, universal healthcare coverage will not solve the problems we face today as it will only cobble together the existing system (which is totally broke)and would lead to rationed care and extensive wait times to see the providers.
    I content that all of the discussions about weather healthcare a “right” or “privilege” serves only as a distraction from the real question that the nation does not what to answer, “What and how much healthcare should be provided when?” Because we have the science and technology we our attitude is “what ever it takes to save a life with disregard for that individuals quality of life” being the current mode of the healthcare profession. That is where the cost comes in. Research shows that 80% of the healthcare dollars are spent on the last two years of life. So the U.S. who spends 50% of the worlds total healthcare dollars thinks it can prevent what was predetermined at birth. I coined the phrase “For a God loving country we sure are afraid to meet him.” Money is not the answer, the U.S. has already demonstrated that we know how to spend and yet we rank in the 30’s among developed countries when it comes to life expectancy. I find it very interesting that we as individuals pay for our house and cars through some form of long-term financing, but expect others to pay for our healthcare.
    The current system is broke and beyond repair. Lets build a completely new system and approach by first answering the following questions:
    1 – What is the definition of basic care?
    2 – What should basic care cover?
    3 – What is the basic definition of “quality of care?”
    4 – What is the basic definition of “quality of life?”
    The healthcare industry uses quality of life and quality of care freely, but when you ask them what that means, the response is “it means different things to different people.” That is a big part of the problem, the industry has not base line to be measured by, nor do they want to be measured. We also need to understand we can’t save and preserve every life equally and attempting to do so is what has us it our current condition. Not sure where I hear this quote that says “we are struck with an irreversible fate at birth – Death, nothing can be done to prevent the inevitable.” However, the U.S. is destroying itself trying.

  11. As a fellow physician (although retired) and as a former health insurance company executive, I want to commend Dr. Friedman for his comments. They are right on point and well stated.
    I may, as he points out, play with words. His words to describe the financial sector- “parasitic and excessive” are perhaps the best description I have seen and they fit the entire system. To those two words I would add WASTED.
    He points out that many insurers operate with 20% or greater overhead while Medicaid operates a 4%. I belive that on closer inspection one would discover a much higher administrative and total overhead cost in all the government programs. The well functioning insurer operates with a 10% overhead and that figure is their goal when they seek to be bought out (merger, aquisition or sale).
    Built into every premium dollar there is a fraud factor. 10 years ago this was 13% (today I would expect it is probably 25% greater). Many of the “fraud” claims are weeded out through claim review but these saved dollars are not reported nor do they reduce future premiums. They fall directly to the insurer’s gross profits. Another source of savings can be found in hospital claims which reveal charges that are not coverable under any insurance package nor should they be claimed as “health” related.
    Dr. Friedman states that most physicians would continue to provide services even if they were rewarded less. I would state that physicians are already being rewarded less when you consider what they might recieve. Medicare and Medicaid rewards are at least 70% less than what the private insurer might provide and contracted health care with an insurer is frequently less than that. We need a national standard of reasonable service reward and not what exists today. Many years ago when I relocated from a midwestern farming state to a more populace western state I enjoyed a 300% increase in compensation for the same services from Medicare (private reward was the same or greater). I can unequivocally state that the cost of living and cost of doing business was not 300% greater but far, far less. What we don’t need is the political pork barrelling and CBO or other governmental alphabet suits doing their actuarial and wasteful reviews.
    As DR. Freidman says, we need a national health care package that is universal. No more uninsured and no more Medicare, Medicaid, and other government wasted healthcare dollars. The war that froze wages and allowed employers to reward employees with healthcare coverage ended almost 65 years ago. Payment for this package would be in the form of a tax on all gross earnings of every individual and corporation. The free market health insurers would maintain their role but with a mandate that at least 85% of all premium dollars would be spent on direct health care of the insured. Savings would result in a premium reduction and that they must accept all (no pre-existing, disenrollment, etc.). Let the free market insurers compete on what they do which is manage dollars and deliver a payment service.
    Universal healthcare is the privilege for which we earn the right to pay. Do it in a system that is logically based and managed by knowing professionals and not the political hacks in local and national legislative bodies.

  12. After reading Dr Friedman’s message, I would like to propose a national formulary be added to his list. There are very many “me too” medicines out there with dubious advantages over their predecessors. The various payors each have their own formulary requiring physicians to keep track of which brand names their patients are eligible to receive. Surely there is enough expertese in the nation to accomplish this.

  13. I chanced on this blog today, and was intrigued by Ms. Maher’s cogent remarks, and by the debate about semantic issues. I am perfectly happy to recognize health as an entitlement, although we will continue to be given dichotomous choices to be made between “right” and “individual responsibility”. I’m on the side of “right.”
    I would like to address a basic economic point, which I did not come across in the discussions. It has always bothered me that a certain amount of money is taken out of health care by the insurance companies and diverted to less pertinent causes, such as administrative overhead, advertising, overemployment, excessive executive salaries, etc., and now we even have data to suggest that they achieve this by lowering their “risk” for having to pay claims quite systematically. The standard quotes are that all this takes 25-30% of the healthcare dollars that they receive, whereas Medicare spends less than 4% on overhead. Hospitals also spend a great deal extra hiring personnel to deal with the multiplicity of insurance companies, forms, and rejections of claims. Knowledgeable people have suggested that if this unnecessary overhead were used for health care, we could provide care for all the uninsured. That seems so basic to the present political dilemma!
    The contrary point I would like to add, drawing a bit on what has been said, is that you can’t completely shut down the insurance industry. There will be limits to the basic healthcare to which everyone will be entitled. Some people will want to pay more to get more care or special care, such as the ever-popular cosmetic surgery. Supplementary insurance will make this possible for them. Not insurance that offers the basic healthcare benefits! That’s paid for by taxes or health fees, a matter of semantics. Not by mandates and preferably not by employers. The risk pool can only be maintained fairly by keeping everyone in it. I think we have learned that by now. But there must be a role for insurance and its host of knowledgeable people, but with tiny profits compared to the outrageous numbers of the past.
    Does this create the possibility of a two-tier system? Well, to some extent it does. But, as someone pointed out above, if the government scheme operates well, nearly everyone will use it and treasure it. One has to be careful that paying a few dollars doesn’t allow one to “jump the queue” to get into hospital. Regulation is necessary. Yes, careful and sensitive regulation is needed in many aspects of the health care system. You can ruin a potentially good system by bad management.
    One other area needs work: the increasing cost of health care. Some of this is due to the increasing profits taken by insurance, but not all. We have heard about the cost of defensive medicine, the unregulated final month of life, the precarious first month of life. We had a marvelous debate about physicians’ salaries–with just a tiny mention of the years of study, the high tuition costs, and the high debt that results–so there are reasons to differentiate what physicians receive. However, like everything else in our free market society, the earnings and the differentials between specialists and nonspecialists have got out of hand. Most doctors do what they do because they like doing it! They would continue even if the financial rewards were not so great. (Although I look at the earnings of those in the financial sector as parasitical and excessive.) Again, sensitive regulation is the answer. And more education for the patients, about health and its costs.
    pjf

  14. I was struck by how Maggie’s initial post and the comments thereafter revolved so heavily around semantics. It is fascinating how incredibly complex it can become to classify healthcare – as deeming it a “right”, “moral obligation”, or “entitlement” can so easily polarize and generate a variety of reactions. I can’t help but feel that the debate is much simpler than this, and that such deliberations by our nation confirm our hesitancy to prioritize access to care. As it says in our constitution, it is our inalienable right to pursue life, liberty, and happiness – but how is one free to do so when they are imprisoned by preventable or curable ailments of their physical bodies due to lack of access to care? It seems simple to me because the state of your body is more fundamental than other societal needs – such as education or financial security. You cannot pursue these other rights if you are not physically equipped to do so. The problem to me seems to lie in the fact that in our present society, we define healthcare as a commodity available for purchase, detaching it from its fundamental and intrinsic relationship to our personhood. Defining medicine by market forces subjects to the principle of purchasing power, ie. “you get what you pay for”. The only problem with this is that the commodity being discussed is not a car or T.V. – it’s your body.
    I am also a proponent of universal health care, funded, primarily, by government taxes. Americans are paying enough already for healthcare, whether it be through insurance premiums or taxes to fund the ER visits made in excess due to a lack of primary care. We might as well be paying into a system that improves utilization and cost of healthcare by removing the cost of insurance companies, expanding access to primary care, and creating a healthier (happier) nation. As over 70% of the 47 million uninsured are linked to an employed family member, this would seem to reward the individual responsibility (including that of XRay) already present in our society and, acknowledging it as a fundamental human necessity, assuage the stigmatism of viewing it as a “right” of the “lazy” and thus “undeserving” poor.

  15. Interesting to include legal representation as a legal right. If health care is a right, then William R. is right. Surely legal representation is a right.
    Mr. Ferreira points out that there is a cost for every entitlement. Also correct.
    And now for a bit of History!
    During WWII, FDR froze wages. In response, to attract and retain quality workers, businesses began to offer healthcare perks (they could have chosen food or housing or even transportation, but I digress).
    It would have been awkward to say, “Well chaps, the War is finished, and so we’re taking away your healthcare plan!” So the plans stayed with us: healthcare glued to jobs. And this wasn’t really too bad, because at the time, medical care had just discovered antibiotics, and odds were you’d die before you could spend too awfully much on trying to live longer.
    But today, medical science can prolong one’s death for years. One can be comatose and unresponsive in a facility. One’s relatives can say, “Please doctor, we can’t give up hope!” And Modern Medicine can keep that body ALIVE.
    (I’ve just been reminded that we have many many people who need me to make money so that they can receive their entitlements.)

  16. One simple comment. “Free of charge” is misleading and a misnomer. There is no such thing. The cost for this is paid by the individual and it is called TAXES. Say that beyond taxes there will be no charge for healthcare. Now define that tax amount.
    One simple question- would William include all cosmetic surgery?

  17. (Short Version)
    To fix the economy of the USA the government needs to:
    Healthcare Reform:
    1. Redefine the term Healthcare to include total body care to restore functionality as far as possible regardless of impairment or disease.
    2. Provide Healthcare free of charge to all citizens of the USA.
    3. Establish a national database for medical history and to monitor therapies, care, and prescription use.
    4. System paid for by grouping all funds and subsidies currently allocated to all programs.
    Legal Representation:
    1. All legal representation should be afforded to citizens free of charge.
    2. Central database accessible to all levels of enforcement agencies that includes all fingerprints, DNA, etc.
    3. Establish forensic laboratories throughout the country to facilitate quick turn around of evidence at no charge.
    Just this will fix the economy, allow for all citizens to keep business operating within the law, and free all citizens to pursue their lifetime goals. Imagine all of the people who could live on their Social Security pension alone. Or the feeling of helplessness that would never be felt again when your doctor tells you that care is denied because your insurance does not cover that device or procedure. This is the only bailout from the government that I will accept. Imagine the cures to disease that could be found when money is no object. Imagine the legal challenges that could keep all businesses operating within the law when lawyers are not forced to consider the ability of the citizen to pay the fee.
    (Long Version)
    To fix the economy:
    The two biggest problems facing USA citizens are Healthcare cost and Legal representation and they should be provided to all citizens totally free of charge. These two items are the cause of many businesses and citizens having financial problems forcing bankruptcy and in some cases narcissistic actions. I firmly believe that if this is done as I have laid it out, more good for the total population of the USA will be done than any number of stimulus packages.
    Healthcare:
    1. Needs to be redefined to stipulate total body care (life with impaired and or no functionality due to no consideration given to things like eyeglasses, dental care/devices to allow for consumption of food, care for replacement limbs, etc.) so that people can lead productive lives.
    a. Present meaning is not inclusive of eye care, dental care, psychological care, mental care, or much of anything else required other than preservation of life without any or other than full functionality of the life.
    b. Various insurance programs insure very little except for procedures for emergency life saving which is useless if the life has no functionality.
    2. Should be provided at no charge to citizens of the USA. This does not require any new offices nor new money just a reallocation of the money spent on:
    a. Medicare
    b. Medicaid
    c. Veteran’s Administration
    d. Veteran’s Health Care
    e. Military Dependents Health Care
    f. Department of Defense Health Care
    g. Government Employee’s Health Care
    h. Federal and State insurance programs
    i. Social Service Programs
    j. Programs for the poor
    k. Children would stay healthier in schools
    l. Children and all other age groups will stay healthier due to NO Stress about doctor bills or prescriptions
    m. Medical community will advance due to more scrutiny of disease, therapy, and prescriptions that work
    n. Loss of tax revenue at all levels (Federal, State, City, etc.) due to inability of citizens to maintain life style due to illness
    o. Loss of productivity of the USA citizens to maintain adequate living on a Social Security Pension plan
    p. Loss of families staying together just so that children can receive some care provided by the various programs not allowed or afforded to married families
    q. USA citizens unable to maintain jobs due to inability to afford eyeglasses, dental devices, prosthetics, etc. to allow their injured or aged bodies some functionality
    r. Foreclosure of homes, forfeiture of assets, etc. due to medical bills that are unregulated and with no means of justification by unscrupulous medical practitioners
    3. A nationwide database need to be established and maintained from the Office of the Surgeon General of the USA
    a. Allows the CDC to be immediately made aware of medical problems in areas of the country
    b. Allows all medical personnel access to medical records of individuals
    c. Allows for the Surgeon General to monitor medications applied and or used
    d. Allows for techniques and procedures and therapies that can be monitored for effectiveness nationwide enhancing the total medical care of the populace
    e. Allows for the benefit:
    i. Of all citizens to have a continuing medical practice scrutiny of the medical profession
    ii. Data could be used also for IRS to locate people via their SSAN
    iii. Data could be used to locate terrorists
    iv. Narcissists that violate the laws (thieves, rapists, murderers, etc)
    v. Assist in locating missing children
    vi. Assist all agencies at all levels that are tasked with safety of the public.
    4. Implementation of this program is fast and simple and will assist in providing Life for all citizens
    a. Require all healthcare costs to be billed to the government in the name of the patient using the patients SSAN (Social Security Account Number) on the invoice listing all billed items
    b. Data collected can be used to create charge limits at a later date
    c. The system can be started immediately and this will straighten out the economy
    Legal System:
    1. All legal representation should be free to citizens of the USA.
    a. Current system is totally dependent on the amount of money that you can afford to determine the amount of representation that you receive
    b. Lawyers forced to make deals rather than to have the judicial system seek proven justice
    c. Majority of citizens are denied fair hearings and fair defense due to lack of funding
    d. Lack of funds for warrant service, Laboratory service, etc. are cause for many case reviews and overturn of verdicts after proof is shown that people were incarcerated or convicted for crimes that they may have been vindicated of at time of trial if they had had the money.
    e. Many narcissistic people prey on those that cannot defend themselves.
    f. Narcissistic people such as gangs, terrorists, and all other acts that deprive citizens of their life, possessions, children, and freedom need to be punished.
    g. For all citizens to be equal under the law, all citizens must be provided the same defense.
    2. Central database needs to be established
    a. For all fingerprint
    b. DNA
    c. Warrants
    d. Criminal charges filed
    e. Accessible by all agencies at all levels to assist in the location of all narcissists.
    f. People incarcerated at any jails
    g. Judgments
    h. Deals made by judges and attorneys
    3. More forensic laboratories need to be established and services provided at no charge
    4. Implementation of this program is simple and fast and it will assist in providing liberty and justice for all citizens. Government receives all billing in the name of the citizen and listing the citizens SSAN (Social Security Account Number).
    Summary for all USA Citizens:
    Unemployment does not pay medical insurance premiums. By taking care of all healthcare and legal cost you will remove the worst things that people have to imagine. Their loved ones getting sick with NO means of affording the prescriptions, the doctor, much less a second opinion, hospitalization or any other medical care. Weather disaster, earthquake, major business closing, fire, disease, pollution of the area that you live, etc. come and go, but if you have the means to care of your loved ones medically and have a means to make sure that narcissistic people could be blocked in court than you can go to another place to live and work as needed.
    Instead of bailout of businesses that failed due to their own mismanagement, the federal government should do the above. As USA citizens we are entitled to Life Liberty and Justice for all so that we can enjoy the pursuit of happiness using the freedoms stated in the Constitution of the United States. The biggest crimes against citizens is that the provision of
    1. Life – depends on how healthy, young, and productive your body remains and how much money you have to receive the items required for your body to allow you to continue a productive life.
    2. Liberty – depends on how much money you can afford to legal representation or legal pursuit of justice if you feel that you have been abused by a narcissist.
    If you believe as I do then send this to all for review and most definitely to your elected representatives. With the election of President Elect Obama, citizens of the USA have proven to the world that public opinion can surpass money in getting things done. Let us make our voices heard.
    William Robertson
    Fayetteville Arkansas

  18. Heathcare is a right. Also food is a right, and transportation is a right. Our government should give us our doctor, our dinner, and our car. Period.
    In this time of such plenty (the poorest Americans are the fattest people in the world), it is an insult and an outrage that anyone should have to buy food, or pay for a doctor, or pay for their car.
    Clearly this extends to housing too. We all saw what happened when the poor were given loans without any collateral. The government needs to provide the poor with free housing. And basic housing means $2500 square feet minimum! It is an insult to the needy to force them into subprime homes (when they just suffered through subprime lending). Many of these forclosed homes are in very nice neighborhoods. Let’s move the most crime-ridden and violent at-risk population to upscale areas. This is exactly what is needed for many inner city gang youths. If they could just move to a nice suburb they would learn to play golf and join the country club instead of gangbang!
    Fact of life. You can’t work, shop or involve your children in activities without a car. A car is not a privilege, it is a NECESSITY. That means it is a RIGHT. End of discussion. For the record I think the government should give the poor really nice cars, big SUV’s with custom wheels and stereos. Think about how that would save the Big 3 Automakers at the same time.
    Back to healthcare/insurance. I believe those who have health insurance should be able to see the coding/biller/adjuster of their choice. They should have whatever code they need assigned to their Protected Health Information, at their Digital Medical Home.
    I believe that any doctor foolish enough to participate in managed care or a government plan (Universal Medicare) is probably not competent to care for an actual sick person, and so most doctors would not practice medicine any longer.
    However, those doctors that remain should be forced to see a minimum of 40 patients a day. Since most doctors will choose other careers we will need more new doctors. Therefore it is important to make medical school much easier and shorter. I have always found it outrageous and incredibly unfair that only smart people can be doctors. This is so profoundly Un-American. Where is the equality people?
    Also, did you ever wonder why healthcare “costs” keep rising, while doctors make about 1/5th of what they did 20 years ago? Oh, except for cosmetic surgery. That is actually less expensive. Could it be because that is the one area insurance hasn’t severed the invisible hand of the market?

  19. Is healthcare a right?
    The arguments provided in Maggie’s original comment opening this thread are very enlightening, especially those of “Shadowfax”. He does not hesitate to plunge into the argument and demonstrate the effects of one decision and its subsequent impact. Declaring healthcare a “right” under our form of government brings up the issue of payment.
    I prefer to look upon this question as one of words as well and have responded to the question in the same way I respond to the “right” of education. Healthcare is an individual right for which the individual has the privilege to pay for it.
    Payment in the US in the vast majority of instances occurs in several forms:
    1. Self pay
    2. 3rd party pay (Insurance)
    3. Government pay (Taxes)
    Irrespective of the means of payment, it ultimately comes from the individual and that must be understood.
    In the case of healthcare, 3rd party payment dominates the landscape. I would propose a national definition of healthcare coverage (a basic plan which for arguments sake is the same as the members of Congress) paid for through a uniform tax. All residents would be covered by mandate and the need for the alphabet soup of plans would disappear.
    I would further propose this as a free enterprise system in which the health insurers would compete by bring required to sell their product to all residents as members of the same risk pool. Would it work? Just look at the Medicare Advantage experience wherein insurers have succeeded on just a percentage of the premium charged by Medicare.
    As to cost containment, I would disagree with the comment respecting insurer’s not controlling costs. They do so through contracting and through other oversight processes.

  20. Me: Self employed 51 year old female paying 490.00 a month. I generally go to a clinic sponsored by Walgreens for blood presure and cholesteral checks because if my BP or HDL were high and my doctor prescribed maintenance drugs I would be rated and my insurance would go up. I do take an anti-anxiety drug occasionaly, but I buy it from India. When my doctor prescribed it, my rates jumped from 410.00 to 490.00 due to a rated condition. I can’t even think of buying a newer car or anything else for that matter. I would love to be able to just buy insurance at a group rate, no government subsidy, just the rate that insurerers offer to those with 100+ employees where the pool is large enough to have enough younger people to keep the rates in reason.

  21. We all know that when we say “Unviversal Healthcare” or ‘right to healthcare’ or however you wish to deem it, what you are saying is that you want the government to take extra money out of the pockets of all who earn money and use that to provide healthcare for anyone who can’t afford it on their own.
    What has the government ever done to inspire you with confidence that they can do this effectively and efficiently and not spend most of that money in beauracratic red tape? How about social security? How about our school systems? Is there some miracle plan to make this work out perfectly well?
    Someone mentioned Canada. You can also look at England. Any nationally used healthcare system is a failure. Today you can walk into any MRI provider and have an MRI done. Under universal healthcare you will not be provided any service in a timely manner. Why? Because the poor will be using up all the time and money and services in a volume never considered. So the busier the providers get the more pushed back everyone’s needed services get. The more pushed back our needed services get the sicker and more injured we become. The sicker and more injured we become the more services we need. You can see where this is going? It’s a neverending cycle. So then the services will start to be rationed out. When the rationing starts we become like wildebeasts in the wild. Our very old and very young will be put at the bottom of the list. Cancer patients over 50 will be right out the door, “Sorry, go home and die in comfort, we can’t help you.”
    And now the mean s.o.b in me. I don’t want Universal Healthcare because I want the money that would go to the sick poor in my pocket to take care of my family and emergencies that come up in my life, let the poor and non-contributing find their own way. There are way too many rags to riches stories and people who came from nothing to great success on their own merits. And now I’m to feel compassion for people who won’t take a shower and get a job to take care of their own health.
    Love YA

  22. “Anyone who calls healthcare a “right” doesn’t care about the right of the providers of this service to live freely and charge their fair price.”
    I don’t think anyone is interfering with your right to live freely or your right to charge any price you wish. However, payers may not want to pay the price you are charging. Do you also feel you have a right to receive whatever you charge?
    Sounds like you are trying to invent some new entitlement program rather than living in a free market economy.

  23. Well said, Dr. R
    Anyone who calls healthcare a “right” doesn’t care about the right of the providers of this service to live freely and charge their fair price.

  24. As I work at 4:45 in the morning running a busy Emergency Department in Las Vegas I can only laugh at the commentary. Just some brief observations: Yes in general physicians are paid relatively well. Compare my salary as an emergency physician to that of a wall street broker, banker, or any upper level management position’s salary. I am the manager of this department if I misdiagnose or make a mistake someones life is in the balance. Do any of these other high level employees have the same level of responsibility. DO you have any responsibility for being accurate about your reporting? Have you ever spent a night in a busy emergency room? Do you think I walk out of my department and the day is just over or do you think that I constantly carry the weight of my decisions inside? I spent 8 years , accumulated more than 200K in debt that I am still paying for after residency – not to mention the 4 years of making very little that where lost during residency working 100 hour weeks. Let the press and government keep pushing and cutting and see what happens to the quality of health care. The smartest people in this country go to medical school to help take care of the lazy, unappreciative, fat public of this country – One day I will be pushed right out the door – perhaps open a business or maybe have invested well and hopefully my replacement can speak english and cares about the people he takes care of instead of the paycheck he is going to send back to India or Pakistan or some other foreign country.
    FYI – Primary care Dr make less money because of there tremendous overhead of running an office and the poor reimbursement by the PIG insurance companies.
    Do some research and actually go to a few real Doctors not some snob nosed Harvard grad for there opinions and see what medicine is like on main street!

  25. I am really glad that this remains the top post on this blog because it shows that people have an interest in the topic of the right to health and there are interesting ideas coming out.
    I see in many of the posts incorrect assumptions about what determines health or sickness, and these assumptions influence what people think about how health care services should be provided. Most people believe that:
    A) “primary care” doctor or clinician services prevent illness;
    B) one’s health status is determined by individual behaviors such as diet, exercise, smoking, etc.
    Regarding A, I can tell you as a family practice physician assistant, that clinical “preventative” services are mostly early detection, not prevention. When diseases are picked up at an early stage they can usually be treated more easily or their worst effects prevented, but most of what we do (besides vaccines and the 2 seconds of health education we have time to give) is early detection or disease treatment.
    Regarding B, public health research shows that the main underlying causes of sickness or wellness are things like the neighborhood where we live, our position in various social hierarchies, our education level and the education level of our parents. Individual behaviors are a factor but probably only account for 15-20% of illness.
    See, for example, the web page of the Robert Wood Johnson Commission to Build a Healthier America:
    http://www.commissiononhealth.org/WhatDrivesHealth.aspx
    or the website of the documentary “Unnatural Causes”
    http://www.unnaturalcauses.org.
    If our goal as a country is to improve our health, then our health system needs to treat all people when they are sick and work to change the conditions that make them sick.

  26. While it is not written in the Constitution or engraved on stone tablets that all citizens have a “right” to health care, we, as a democratic society, have evolved to a point in our sensibilities that we think all citizens should have access to reasonable health care. The first reaction of many people is to have government provide and control it. The problem here is economics. As demand outstrips supply the cost, quality, and available resources cannot keep up. What to do? I have a radical out-of-the-box idea that will seem extreme now but will grow more plausable as the cost of health care threatens to implode the existing system. That is especially true with all us boomers starting to retire. I suggest we determine the actual cost to all governments (federal, state, county, local) per annum to provide health care. That would be the costs to primary health care givers and ALL costs to run all the health care bureaucracies. That would include salaries, retirement funding, benefits, purchase and leasing of buildings, insurance, maintainance,etc. Take this colossal sum and divide it buy the number of citizens.( That should be enough to pay for a good health insurance policy for everyone.) Next, eliminate all (or most)health care bureaucracies completly. Make a new small bureaucracy whose job it is is to verify citizenship and addresses of all persons. Once a year each citizen is provided a government health insurance voucher. It can only be used to buy a policy. Each citizen can then go into the free market and shop for the policy of their choice regardless of their employment or economic status. Congress should pass legislation mandating what has to be in every baseline health insurance policy so everyone gets the basic necessary and essential care they need. Also, anyone applying for a policy cannot be refused and cannot be dumped. If someone wants a policy with more frills they can pay for the extras themselves or purhaps with money left over from the voucher above the cost of a baseline policy. This would help spread the risk around for the insurance companies. Also, it would help end a lot of the fraud that is in the system and competion would keep costs down. I know this plan is politically impossible. Too many people are in love with the idea of the government taking care of everyone and politicians use these programs to get votes and have power. Personally, I think this idea is a compromise. Government collects the taxes and disperses the vouchers, citizens are responsible for selecting their own policies, and the free markets control cost. It gets government out of the examining room and lets doctors practice medicine again. I put this out there as a thought experiment and to generate some thought.

  27. When a country’s leaders and those with influence are effective in getting most people in that country to agree that even in a global economy and internal dependency on many factors outside their control that (A) they are at fault no matter what, (B) have no rights to basics needed to survive or exist, (C) they should vote against their own economic interest and the interests of others, (D) that the fundamentals of democracy and economy are sound even when 5% of the population owns or controls 95% of the wealth of that country, (E) the tax reductions and political process that favor one class over the interests and needs of all the others and caused and encouraged the redistribution of wealth from the 95% [poor, lower and middle classes] to the 5% is acceptable by calling it capitalism, but the redistribution of a small part of legally and illegally gained wealth owned and controlled by 5% of the population to the 95% of the population is not OK because it is called socialism and (F) that those who accept it as their right to be wealthy beyond any definition of need should not pay a fair share of the taxes needed to pay for wars, social services, ransom bailouts, interest on government debt, etc. and the welfare they get every day, then a silly question about medical care being a right might seem like a correct question to ask.
    We should be asking many other questions.
    How do we reverse this campaign to destroy American rights and democracy by permitting 5% of the population from owning and controlling 95% of the wealth?
    How do fairly require that all Americans pay their fair share of the expenses of running America, here at home and overseas?
    How do we reverse the 30 years of socialism that caused and encouraged the transfer of 95% of the wealth of America to 5% of the population?
    How do we restructure (change) the components of America that are not good for families, individuals and employers?
    Here are two recent examples of the statement that the level of concentration of wealth is wrong for democracy.
    1-Recently Americans expressed from the right, middle and left of the political spectrum that they were opposed to the welfare payment of $700 billion to undeserving CEOs, banks, brokers, stock traders, insurance companies, and others associated with Wall Street. They were outraged that those 5%ers lived off the fat of the land, had accumulated incredible wealth and whose unregulated actions caused the economic meltdown should demand a ransom without preconditions or controls. The Congress repsonded at first democractically but then was in the eyes of the whole world was put on the slave block and sold. $700 billion of wealth is now being redistributed from 95% of Americans to the 5% of the population.
    2-Three billionnaires decided that rewriting the laws of the City of New York to allow one of them to run for a third term despite two referenda limiting terms to two to promote democracy and end rule by one man. I do not think there has ever been a woman Mayor. The initial reaction of rage won the support of the City Council which soon saw some of its members switch votes claiming the two prior referenda limiting terms were undemocratic, that another referendum would cost a few million and that it could not be done in time and overturned the law limiting term limits. To buy some votes, City Council members can now also run for a third term. An argument used to try to gain support was that only this one billionnaire could take New York City through the financial crisis. That billionnaire’s net worth increased from $5 billion to $20 billion in the last eight years. What was not said was that this billionnaire was running to protect himself and other billionnaires from the economic fallout.
    An example of one component of our society that needs restructuring not expansion is the way we provide and pay for medical [not health] care. Expansion of medical care insurance is not an answer. Medical care received (MCR) is too costly, often dangerous [is now one of the top leading causes of death in America] and ineffective, that is, many treatments, tests and prescription drugs have not been proven to be better than doing nothing, doing something else that is less costly and less dangerous. Prior to expanding MCR, America needs a National Wellness and Health Status Improvement Program that empowers people to make an effort to avoid and primarily prevent disease.
    Let’s take one example, lung cancer. A known killer with little relief by MCR and costly to address. Primary prevention by reducing the level of personal life styles that are associated with this dreaded cellular dysfunction can be done for a lot less money and make a people happier and healthier. Imagine going to your next July 4th party and talking about how healthy you feel without, let’s say tobacco, and how much more vibrant your life has become since you learned to keep moving [exercising walking, running] all day and are eating healthier organic and natural foods then to listen to the tales of woe of those friends and family members who have lung cancer, and the pain, discomfort and hair loss due to the MCR and how terrible it is to fight with the insurer or HMO to get bills paid for covered and denied services, increasing deductibles, taking pills for pain and pills to cover the problems caused by the other pills and how you have no energy, can’t eat or sleep and regurgitating all the nonsense that your doctor, nurse and therapists told you and knowing that in six months, maybe a year your a gonna anyway?
    The choice is clear is you want to restore democracy.
    You need a change.

  28. Maggie,
    I respect your opinion but speaking as a person who grew up often without food, much less heat or electricity I do resent your insinuation that I am some sort of wealthy elitist.
    You wrote: “Try to imagine a family of four, with joint income of, say, 49,000 (well above the poverty level), paying for housing, utilities, food, car repairs, gasoline, car insurance, home insurance, clothing, and perhaps, trying to save something for their children’s college education or their retirement.”
    I can, I’ve been there. We need to expect people to start living within their means. When money was tight, my wife and I did not have kids because we couldn’t afford them. When money was tight, we didn’t have cell phones or new cars or big screen TV’s or even cable. You make decisions based upon needs not desires. I didn’t feel like anybody owed me a cell phone or a new car. I couldn’t afford it so I didn’t have it.
    You also wrote: “As for putting money into an HSA–you have to be kidding. Only the very wealthy have money to fund an HSA– after trying to save for retirement and childrens’ college. That’s why only 2 percent of the population has an HSA.”
    If you think a family making $50k/year cannot find $2000/ $166 a month to scrape together in a year then you are living beyond your means. I would be willing to bet these families cell phone bills account for that much money. I’m certain that if you combine cell phones and cable TV they would be saving far more. You may beleive healthcare is a right but how about cell phones and cable TV? Should we subsidize those bills as well?
    And you had better get used to the HSA idea because more health insurers will be turning to this HSA/HDHP model and turning away from the HMO’s. So regardless of if you think my solution is workable or not most people will eventually have an HSA or they will have no insurance.
    Did you even read the full proposal? If you and your family live a healthy lifestyle you wil not even use your pre-tax HSA funds. All preventitive healthcare is free. You only need to use your HSA funds if you or a family member gets hurt or sick. It’s very likely that most people will end up with more money in their HSA than they will ever need for healthcare. And if this is the case this leftover money can be used to supplement their retirement. A nice little bonus for living a healthy lifestyle!
    As I stated the deductible will be based upon income as well as familiy size. If you make more money you will have a higher deductible. If you have a larger family you will have a higher deductible. It will be a well known fact that any right thinking individual can budget for. “We need to make this much more money in order to be able to afford another child.”
    My goal is to remove the need to make a profit from life or death decisions. If I or a family member of mine needs a life saving transplant I don’t want the person on the other end of the phone assessing if it is profitable to do so or not. I want them to simply know that this is a person who needs help.

  29. Noah–
    You write: “All families above the poverty line would be required to meet a yearly deductible via the proliferation of HSA’s (we could potentially explore the possibility of letting people access their 401k’s to either fund the HSA’s or pay for medical expenses). The deductible would be directly linked to the family size and income level. Larger families have a larger deductible as do wealthier families up to a cap. After meeting the deductible the single payer system takes over similar to a high deductible health plan”
    I’m wondering if you realize that half of all households in the U.S. have total joint incomes of less than $55,000–before taxes.
    That’s half of the population.
    Try to imagine a family of four, with joint income of, say, 49,000 (well above the poverty level), paying for housing, utilities, food, car repairs, gasoline, car insurance, home insurance, clothing, and perhaps, trying to save something for their children’s college education or their retirement.
    Imagine how much money they have left over, after paying taxes, and for the necessities of life. Where would they find a few thousand dollars to cover a deductible? They wouldn’t.
    And heaven forbid that they have three or four children (maybe they had twins!) They are now penalized with a higher deductible, while their ability to cover it is diminished.
    As for putting money into an HSA–you have to be kidding. Only the very wealthy have money to fund an HSA– after trying to save for retirement and childrens’ college. That’s why only 2 percent of the population has an HSA.
    I realize you’ve put thought into your proposal. But I
    suspect that you are either single, or living in a household where total income is somewhere north of $75,000 –roughly 50% higher than median household income. In other words,you are much wealthier than half of the nation.
    In the U.S. we tend to only know people who are in our income bracket (or much, much younger or older.) As a result, if you’re upper-middle-class (earning significantly more than median income) it’s hard to realize that the majority of Americans have watched their incomes stagnate or fall over the last 20-25 years. They don’t save because they don’t have any money left over at the end of the month to save.
    And neither market-driven nor consumer-driven healthcare will help them. What they need is a healthcare system where everyone (young or old, healthy or sick) pays into a common pool, based on their income (just as we do for Medicare)and everyone receives the same benefits package.
    That’s the way it works in the vast majority of developed countires. And they spend much less per person than we do, while having much better healthcare and overall health. (Their overall health is better becuase they don’t tolerate the level of poverty that we do; instead they pay much higher taxes to fund social programs.)

  30. I propose that we use the consumerism model being employed by most health insurance companies as a basis for real universal healthcare. We can use this model to institute a true single payer national healthcare system without losing the benefits of a competitive free market. All preventative healthcare such as physicals etc. would be covered 100% as well as all families under the poverty level would be 100% covered. All families above the poverty line would be required to meet a yearly deductible via the proliferation of HSA’s (we could potentially explore the possibility of letting people access their 401k’s to either fund the HSA’s or pay for medical expenses). The deductible would be directly linked to the family size and income level. Larger families have a larger deductible as do wealthier families up to a cap. After meeting the deductible the single payer system takes over similar to a high deductible health plan. The national healthcare system will provide payment for standard prescribed services beyond the consumer’s deductible. Where I would differ is the consumer would still retain the option of using any additional funding in their HSA to pay for additional services, such as private service rather than public, advanced treatments etc. using tax free HSA money.
    This strategy has multiple benefits including:
    Everyone is covered and no one is forced to buy anything.
    Regardless of income level all citizens are covered and able to receive the medical care they need. No one is unfairly burdened by being forced to pay for insurance they cannot afford. Medical costs will not be inflated to cover the costs associated with treating the un-insured.
    Consumers become more engaged in their healthcare decisions. Lowered healthcare costs.
    By voting with their dollars consumers will be better positioned to drive innovation and control medical costs. Similar to shopping for an auto mechanic or construction contractor the consumer will be allowed to research and seek out the best services for the greatest value.
    The public will have a financial incentive to maintain their health.
    The healthier you are the less you will spend on healthcare. Un-used HSA funds can be used to supplement retirement income should the consumers health and financial situation warrant it. Consumers who maintain a healthy lifestyle will be rewarded with a healthy, tax free, supplemental retirement income thanks to their careful planning and proper choices.
    Consumerism creates open market entrepreneurial opportunities.
    The competition for consumer dollars will create businesses and drive innovation. Along with the new businesses will come jobs and new opportunities for high quality low cost healthcare solutions.
    Alleviates many of the known pitfalls associated with other national healthcare systems.
    Through the melding of consumerism with national healthcare we can limit or remove many of the common complaints associated with other national healthcare systems. Long wait times for service will be limited by the competition for the consumer’s dollars. Stagnant medical innovation would also be eliminated via increased competition brought about via consumerism. By allowing those with the desire and means to do so to use HSA dollars to fund out of pocket expenses for advanced or un-orthodox treatments we can encourage and drive innovation that may eventually become the standard in the future providing an ever better quality of healthcare for all.
    Obviously this is a very high level outline and does not get down deep in the weeds. I do feel however that this can be a very workable solution. The health insurance companies are clearly staking a lot in the success of this methodology to maintain profitability going into the future. If they can use this to be profitable, a not-for-profit single payer system should easily be able to break even without costing more to the consumer. Even if it is government run! J
    I’m all for using profitability as a driving force where it makes sense to do so. In my opinion, health insurance simply doesn’t fit the mold. One of the easiest and most common ways for a health insurer to make a profit is to deny claims. With the need to make a profit, denying a claim is reduced to simply a way to make a buck. Remove the need to make a profit and the playing field changes. No longer is the person who needs an expensive transplant on the other end of the phone simply an income drain. Suddenly they are a person, a mom, a dad, a brother or sister and they need help. Life is too precious to be left to profitability.

  31. Before he dropped me without notice, the heart surgeon told me that it was my responsibility as an American citizen to have health insurance.
    I have had health insurance, I just didn’t have any when I had a heart attack. Every place I have ever worked for, and I have worked for some big companies, has gone out of business.

  32. Before he dropped me without notice, the heart surgeon told me that it was my responsibility as an American citizen to have health insurance.
    I have had health insurance, I just didn’t have any when I had a heart attack. Every place I have ever worked for, and I have worked for some big companies, has gone out of business.

  33. bc–
    You write: ” i would like to continue to have this option available to me. and if i need to pay a few more dollars a year in taxation to provide basic healthcare access to those who fall through the cracks, i’m all for it. besides i’ll bet if we can eliminate the waste in the system my personal costs would be lower anyway .”
    If only everyone were so enlightened. I agree with almost everything you say. Containing costs and improving quality (which goes hand in hand with less waste) shoudl be the goal of reform– affording care for everyone then becomes relatively easy.

  34. nobody has a right to good health. it is given by god. but if we must consider our healthcare as some sort of government responsibility ( although i must admit i find it hard to locate in our constitution ) let’s first clean up the waste and excess in in the industry. the problem isn’t underinsured of uninsured people, it’s the need for insurance at all. the mere presence of insurance companies involvement in our healthcare drives up costs, disassociates doctors and their patients, and creates huge highly profitable entities that suck massive amounts of money from the system. There should also be some legal reforms to limit malpractice claims. maybe if we return to medicine being practiced without lawyers and insurance men profiting from the system we can all afford to provide for ourselves. of course there will always be those who cannot afford medical treatment. perhaps we could provide a national network of care for the underpriviledged via an expansion of the va system and local immediate care facilities for those who qualify rather than forcing us all to join into some enormous bureacracy that would dictate the terms of our heathcare and treatment. i personally have provided for the needs of my family (six total) for over 20 years. we carry a very high deductable major medical policy to cover anything catastrophic and pay for services we need, negotiating cost directly with the physicians we use. this has proven to be a very cost effective way to manage our needs and i would like to continue to have this option available to me. and if i need to pay a few more dollars a year in taxation to provide basic healthcare access to those who fall through the cracks, i’m all for it. besides i’ll bet if we can eliminate the waste in the system my personal costs would be lower anyway

  35. its strange that some people see education as a right – but healthcare not. without education you don’t die – but without healthcare, you can and some will.
    as a chronic ill person who will probably never be able to take care of myself i am very happy i dont live in the usa. i never chose to be ill, ive never had a chance to make money to pay for insurance since ive been ill from young. life is a bitch when you’re ill. you dont become ill for fun as some people assume.. disability welfare is barely enough to live from, for me going out of the house is too expensive (since i cant walk and cabs/healthbusses) i wish those people who think someone is ill for fun go live my life for a week then they see it no fun. healthcare is a must for people like me to survive (survive, not even live), it makes me very upset in countries like the usa most people rather see you die than help you.

  36. To Maggie:
    You are essentially right with your salary figures, and I never wrote anything else. All I can say is, if one takes your first post about physician salaries as a general rundown of what doctors make in the US, it is somewhat overestimating salaries, for the 2 reasons that I already listed above. Read as s a proof for your 700 K claim (and that was your actual intent), the post is perfectly accurate. Thank you for providing the link.
    If you had the best and most recent “overconsumption” article at hand, I would greatly appreciate if you could post the reference.
    To Barry:
    First of all, I worked in the US for the last decade, and although I am in touch with a few German physicians, I can give you only a very rough idea.
    ad 1): Pay in Germany varies most dep. on specialty and whether you are a hospitalist or in private practice (which means largely seeing outpatients, but some surgeons do admit patients because they have special priviliges “Belegaerzte”).
    Shooting from the hip, hospitalist attendings are well below 100 K Euro. In private practice, your incomes vary from well below 100 (e.g. psychiatrist in solo practice) to the few 100s (top earners probably being radiologists and laboratory docs, especially if they own costly eqipment).
    ad 2) More variable in France and Germany vs. the US. In the former, you encounter doctors who simply state: it doesn’t make sense to do XY in this situation (age, comorbidity) … while XY always will at least be offered in the US, for fear of litigation alone.
    ad 3) see 2) Litigation is increasing in Germany, but still at a tiny fraction comp. to US levels. The sums in play are also much lower.
    ad 4) re. premies (never worked in a related field, but heard and read about it) – equally aggressive. End of life … somewhat less aggressive, with more variation (see 2).
    ad 5) Not really, I am afraid. The problem does exist, for sure.
    ad 6) I think that nongeneric specialty drugs are 20-40 cheaper, like in Canada, maybe even cheaper than that (generics are also cheaper). It is still a lucrative business, there are pharm reps, and the companies have influence (years ago, the pharm lobby apparently prevented the introduction of a “positive list” as guideline for good generic use in Germany).

  37. “Two-tier when done correctly…”
    “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.”
    I think you just made my point kdent7.

  38. 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.

  39. 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?

  40. 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 😀

  41. 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.

  42. 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.

  43. 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

  44. 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.

  45. 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.

  46. 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.

  47. 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.

  48. 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.

  49. “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?

  50. 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.

  51. 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.

  52. 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.

  53. 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.

  54. 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.

  55. 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.

  56. 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.

  57. 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.

  58. 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 . . .

  59. Marco, if your point is road builders can chose other work not to be “enslaved”, then why is that not true for doctors?

  60. 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

  61. 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.

  62. @ 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.

  63. “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.

  64. 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.

  65. “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?

  66. 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.

  67. 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.

  68. 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.

  69. 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.

  70. 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.

  71. 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?

  72. 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.

  73. 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.

  74. 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.

  75. 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.

  76. 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.

  77. 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?

  78. 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.

  79. 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?

  80. 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.

  81. 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.

  82. 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.

  83. 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

  84. 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.

  85. 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.

  86. 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.

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