OP-ED

Healthcare: Right or Responsibility?

Steven schimpffDuring the presidential debates, Tom Brokow asked, “Is healthcare a right, a privilege or a responsibility?”The candidates did not answer the question, but now would be a good time for Congress and the Obama Administration to balance the rights being offered as part of reform with corresponding responsibilities.

We are the only developed country that does not assure all of its citizens basic medical care insurance access – shame on us. We spend more per capita for medical care than any other developed country yet our outcomes are not the best – shame on us. We mostly use price controls to try to slow rapidly escalating costs. They not only don’t work but leave patients with less than adequate care and huge bureaucratic frustrations – not logical. All too many individuals find that they are denied coverage because of a preexisting condition when they move from one job to another or find themselves unemployed – unacceptable. As a population we have all too many adverse behaviors such obesity, lack of exercise and smoking that are leading to expensive, lifelong chronic illnesses like diabetes and heart failure – killing ourselves. And primary care physicians find that they do not have time to offer good preventive care nor care coordination to those with chronic illnesses because insurance does not pay for these essential activities, thereby resulting in more visits to specialists, more expensive prescriptions when life style changes could have been effective, more procedures and tests – all of which lead to higher total costs of care.

Howard County, Maryland has instituted a program called Healthy Howard that offers the uninsured access to primary care for a minimal fee along with specialist care given pro-bono and hospital care for no charge. But in return, each patient works with a health coach to develop a set of goals for the year such as weight control, smoking cessation, exercise enhancement or stress reduction. Patients also are expected to receive appropriate vaccines and obtain basic screening such as checks for high blood pressure. The health coach assists the patient to overcome barriers to success such as helping to find a free smoking cessation program or an inexpensive gym. Patients have been pleased with the program and responded well to the responsibility element. It is a model balancing rights with responsibilities that is worth emulating.

Congress is rightly seeking to assure all of access to care regardless of ability to pay. It is not inappropriate for the tax payer to expect the individual in return to lead a reasonably healthy lifestyle as a means to not only maintain and improve health but to lessen the cost of care? Congress also plans to ban the practice of insurers excluding individuals with predisposing conditions. A reasonable expectation [responsibility] in return is that everyone participates in insurance so as to keep the risk pool large and the costs down. In another pairing of rights with responsibilities, commercial insurers and Medicare should be able to incent patients to hold down costs with premium reductions for those who do have an appropriate weight, do exercise, do not smoke, do get their vaccinations and do have screenings done.

Primary care physicians should be able to have a reasonable income without a huge patient load nor the necessity of short visit times but in return the insurer/payer should be able to expect excellent preventive services and good coordination of the care of those patients with chronic illnesses. In this model, both doctor and insurer each have their rights and each their responsibilities, resulting in better care, healthier patients and reduced total costs to the system. Government, and therefore the taxpayer, in accepting the responsibility of universal coverage for those who cannot afford it should have the right in return of a reasonably healthy lifestyle by those covered. The result is better health with lower costs over the long term.

This combination of rights and responsibilities can assure that everyone has access to care and incentives to better health. Yet, it will reduce expenditures through improved quality and eliminate many of the current frustrations with the “system.” It satisfies the legitimate arguments of those who insist that medical care is a right with the equally important argument that we all have to accept a meaningful level of responsibility for our health and its costs.

Dr Schimpff, who blogs at http://medicalmegatrends.blogspot.com, is the retired Chief Executive Officer of the University of Maryland Medical Center. He is a consultant to the United States Army on mechanisms to interdigitate high technology into improved patient safety in the “operating room of the future.” In 2007, Dr. Schimpff authored “The Future of Medicine”, a book focusing on genomics, technology, imaging, stem cells, and the future of the OR and information management. Learn more about The Future of Medicine book and podcast at http://www.medicalmegatrends.com.

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47 replies »

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  2. lol, peter do you even read what you post?
    “And what U.S. hospital would let someone in with no health insurance?”
    Um that would be only ever hospital in the country seeing as how its a federal law.
    “It’s hard to argue with someone when all they have to bolster their position is misinformation.”
    This he actually is right about, how ironic it follows a factual error and preceds further misinformation.

  3. hum Peter sounds like someone doesn’t have an argument so they try dismissing my points. If you had keep quit and not said anything then you would have let it gone, instead you claim I am misinformed then fail to counter even a single point. I bet your the type that says not to offen anyone right before you offend them. Or Your not one to gosspit right before you do?

  4. “And this flood of tales about Canadians coming south for needed treatment, waiting lists, shortness of modern diagnostic equipment, delayed surgery, unavailability of certain medications, these are contrived of whole cloth by “right wing” wack-a-doodles?”
    YES!
    http://new-canadian.blogspot.com/2009/06/are-canadians-flocking-to-us-for-health.html
    http://content.healthaffairs.org/cgi/content/full/21/3/19
    http://www.cbsnews.com/stories/2006/10/18/health/webmd/main2104425.shtml

  5. Nate, you are so intentionally misinformed I won’t even attempt to discuss this with you.

  6. The long and short of it is that the well-insured know they are getting better and more timely care than their Canadian counterparts. Cold, hard, uncaring, selfish, greedy bastards–just like the Kulaks.

  7. Healthcare in canada has long waiting list, rationed care by dictate, and caps on consumption. Not that these things are always bad but you can’t honestly compare the cost of such a system to the cost of a system that allows you to walk in and have an appointment two days later. Our system also allows people to make more of their own decisions and try treatments other systems won’t allow. Again not saying this is good but that freedom comes at a cost.
    Medicaid is proof we can provide that type of system at cost equal to what other nations spend. The point is that is not the system Americans want.
    “Why would they be advocating for less cost for what they don’t pay for”
    Why do my gay male friends have the strongest pro abortion beliefs? Who advocates for reform? Politicians, they don’t pay for their care. Union bosses, they don’t pay for their care. Uninsured who, although 75% could have insurance, choose not to be insured, want a “cheaper” system. None of these people have skin in the game. Study after study shows people that have insurance like it and want to keep it. That is why “reform” keeps failing, it isn’t fixing what people want fixed it is taking away what they like. Reform is about money and politics not making the current system better.
    I’ll bet you your neighbor says he wants lower premium for his company but hasn’t done anything to get them. Everyone wants the magical solution that lowers their cost 40% and doesn’t require them to do anything. This is phantom reform, there is no such thing. Now ask your neighbor if he wants to have a single payer plan funded by taxes 125% of his current premium and see what he says. He doesn’t want that reform either. Has he looked at high deductibles and self funding? Has he had any of his employees order their Rx online? There are plenty of ways to lower cost, they just take work. Many small employers will complain about the cost but the cost isn’t bad enough for them to do something about it yet.
    Medicare is so so becuase it is slow to adapt, only adding Rx in 2006 for example. Non existant care managment and disease management. Terrible customer service, no member interaction. Minimal education. No claims management. inadequate reimbursement for some types of care, i.e. PCPs, others over paid. By shear spending it delivers decent benefits, but it is terribly inefficient and misses out on to many opportunities.

  8. Nate, why is Medicare just “so so” compared to private plans (disregarding the fraud issues)?
    ExhaustedMD, I believe most people agree in principle that everybody dies sooner or later and most people would even agree that in many circumstances sooner is preferable. Most people also agree that eating right and exercising is the right thing to do. The problem, as usual is the execution.
    Agreeing in principle and agreeing that my grandpa, or my baby, must die today are very different things.
    Agreeing that my grandpa has to die today, while the grandpa in the next bed can go to Duke Medical Center and get more treatment, just because he happens to come from a wealthy family, or because he spent his younger days on Wall Street, while my grandpa “only” taught math to kids in the city, is unpalatable.[story here is purely fictional]
    However, I really don’t think that end-of-life expenses are the only, or even the main, reason for our health care problems. There are addressable flaws that don’t carry such enormous emotional baggage. We could reduce waste and fraud and we could reduce profiteering (by everybody involved) and we could make more people pay into the pool earlier. We could increase efficiency and improve research on what works and what doesn’t and apply the results. We could care for more children and younger adults in the hope of reducing costs later in life. And so many other little things… And the secret to success is doing the little things right.
    I think that is what the much maligned health reform bill was attempting to do.
    And I don’t believe a vow of poverty, ala Mother Theresa, on your part would be either required or expected.

  9. You know what people are afraid to say, much less admit to themselves more often than not? People die, and sometimes they die sooner than we, as involved others in such an individual’s life, want to experience, as much I am sure the dying individual wants to face.
    The biggest problem in this health care mess is we keep some people alive longer than they should live. There, I will take the risk, and guts, to put this out here in this debate. So, when ALL the involved parties to health care changes are ready to accept this basic premise, that being the patients, invested significant others, doctors and other health care providers, insurers, regulatory bodies managing health care, and employers who are involved in health care payments (and by the way, this is the order of most to least importance to true health care decisions in the process), then and only then can the system be altered to be more efficacious, responsible, and financially prudent.
    Species have limits, as overpopulation only weakens and increases risks not only to the group, but to the synergism and symbiosis of other involved species.
    Chew on this, folks.
    By the way, again, where was this vow of poverty I missed signing when I finished medical school? And why I am the few of this profession asking this question as more and more NON providers seem to be forcing this expectation on the profession of medicine?
    Time to take the F-O-R out of profit in health care!!!

  10. The bottom line is that nursing home funding, in Canada, is largely left to the individual provinces with spotty, and often deplorable results. I am pleased to see, however, that they seem to be making some progress on home visitation by those acutely in need of care.
    And this flood of tales about Canadians coming south for needed treatment, waiting lists, shortness of modern diagnostic equipment, delayed surgery, unavailability of certain medications, these are contrived of whole cloth by “right wing” wack-a-doodles?

  11. “Canadian health care is maybe slightly better then our Medicaid.”
    Explain how?
    “The same people “advocating” for less expensive healthcare are the same people that don’t pay for their healthcare now.”
    Why would they be advocating for less cost for what they don’t pay for, unless they’d like to pay for it but can’t afford to. Are companies struggling to keep coverage for their employees and want less expensive not paying for their healthcare. My neighbor, whose company policy premiums went up 43% this year, is advocating for less cost, he’s paying for it. Maybe a liberal hate line will bolster your argument.

  12. apples and oranges Peter. Canadian health care is maybe slightly better then our Medicaid. Have you compared Medicaid spending to Canada? They aren’t far off. American Private Insurance is heads and shoulders better then Canadian healthcare and cost more. Finally we have our most expensive plan, Medicare which is so so but cost an arm and a leg, about a foot and wrist of which is fraud and waste.
    If we all wanted Medicaid we would be price comprarable right away, 80%+ of us prefer what we have though.
    The same people “advocating” for less expensive healthcare are the same people that don’t pay for their healthcare now. Its hard to pay less then zero.

  13. archon41, you mean this:
    http://www.cbc.ca/news/background/nursing-homes/
    Here is a Canadian report on elder care across the country which deals with those care facilities under the federal health act and those not, which would be provincially regulated.
    http://www.acewh.dal.ca/eng/reports/The%20Status%20of%20Canadian%20Nursing%20Home%20Care.pdf
    And here is one about U.S. nursing homes:
    http://www.nccnhr.org/node/227
    Seems the problems are about the same, funding, funding, funding. Were you referring to privately funded or publically funded, because I’ve seen less than standard care in publically funded private nursing homes in Canada and the same here? I’m not sure why you threw this out when long term elder care is a different issue than medical care. I guess you were just looking for some negative about Canada. I’ll admit they aren’t perfect and it’s not a health care paradise, but they do muddle through and provide good care at about half the cost, if Canadians want more then they can advocate to spend more tax dollars. So far Americans advocating for less expensive healthcare have been unsuccessful beating healthcare lobbyists in Washington.

  14. Actually, I kinda see eye to eye with Nate and W.C. Fields on children.
    If you think Canada is so far ahead of us, Peter, I would encourage you to take a look at what passes for state-funded nursing home care up there.

  15. “In the old days when we went to the Butcher to get a cut of Meat. If it was too expensive, the service was poor or the product was Bad. We would seek out another butcher. Of Course, this was before Corporations closed the doors on individually managed Businesses and stifled Competition.”
    Small local butchers have a hard time competing on price and probably don’t do it as they now concentrate on “finer” cuts for niche customers. In my area we can also get local grass fed field raised meat with no antibiotics – healthier for man and animals. Prices for meat have fallen because of large corporate operations, especially for the fast food industry. I will concede there are far less local butchers, replaced by large supermarket “price is king” stores, as small local operations/abbatoirs have been replaced by feed lots or corporate controlled chicken operations.
    Of course what has suffered is animal welfare and large nationwide outbreaks of E-coli as well as drug infested meat and probably massive local pollution where feed lots are located.

  16. “Of Course, this was before Corporations closed the doors on individually managed Businesses and stifled Competition.”
    What in the world are you talking about. I have 3-4 dozen butchers close to me in Vegas and in Ohio a dozen of different ethnic variety. If I want cheap and affordable meat I can go to my evil corporate butcher at the grocery store, if I want something special I can go to the little niche guy. Far from losing options we have considerably more options then ever before.

  17. While Health Professionals are going to their college of Choice. How much in Government grants and Low interest Government Loans have contributed to the delivery of a licensed Professional? Taxpayer dollars has made it available to offset some of these Costs. A Few years ago,Hospitals in California were closing the Emergency Rooms because of uninsured immigrants.The Federal Government used taxpayer money to bail them out. A subsidized Comodity?
    In the old days when we went to the Butcher to get a cut of Meat. If it was too expensive, the service was poor or the product was Bad. We would seek out another butcher. Of Course, this was before Corporations closed the doors on individually managed Businesses and stifled Competition. Since that time, product and services have suffered and prices have sky rocketed.
    This is true with the Product and Services of Health Care as well. Corporate power and influence has vastly compromised the Value of Service, productivity, staffing and Patient Safety.
    Patients Have Rights to expect proper staffing,proper and expedited services from Competant Professionals and a significate improvement in Patient Safety and Hospital Acquired Infections. To often these rights have been ignored because the Corporate industry is more concerned about themselves,than providing the best of Care.

  18. archon41, we could argue all day as to what’s included in adaquate or equal, but if you apply that wordage to education would you also separate adaquate and equal? Is adaquate for Medicaid patients getting the same aggressive cancer treatment care at the same hospitals or making sure they don’t have access to your premium care? I don’t know why you’d want to separate people as to level of care, and I’m not talking cosmetic surgery? In Canada you pay extra for private or semi-private rooms but you get access to the same docs and treatment and are not treated differently even if you’re in a ward, to me that’s adaquate and equal.
    “Are you seriously proposing that Medicare reimbursement rates be hammered even lower?”
    I can’t say exactly how rates should be distributed but I would pay more for PCPs and lower for specialists, I would pay more for remote areas having trouble getting docs, but yes generally I would drive Medicare rates lower, providers (mostly hospitals) would have to trim their costs to stay in business. But I’m actually for universal budgets because it’s the only way to rein in costs, but that would involve single-pay, which I am an advocate of and for which hospitals could expect payment for treating everyone – no bad debts. If you say Medicare needs to pay more then the treadmill of ever increasing costs never gets addressed and the taxpayer is held captive to subsidzing over use and inefficiency. Yes I can be for subsidies, just not open ended ones with no cost controls. The more costs increase the more you need subsidies. It’s not the entitlement of private business to have the taxpayer continue to fund their ROI while not expecting something in return.
    “I see you have chosen to ignore my point that employers who have elected to self-insure aren’t saving all that much. They’re hurting too.”
    Actally I didn’t include self insured, but the reason they’re hurting is because the system has no way to control costs/prices except to shed more and more people unable to afford coverage. I doubt self insured plans pay their administrators millions in bonus money like BCBS does.
    “I don’t understand your objection to means-based Medicaid. We don’t need people in nursing homes at our expense sitting atop handsome portfolios.”
    For healthcare I don’t think anyone should be means based for acess and treatment, if you control costs, but I think payment for healthcare should primarily be through the tax system which would automatically make it means based, most everyone could afford to pay something. No, I don’t agree that people with sizable assets should get to keep them just to pass on to their children while the taxpayer funds their nursing home, but I’m not sure what people you’re talking about – maybe that’s something we can agree on.

  19. We won’t answer this question, because since everyone is covered [eventually] most don’t see the problem is in the question.
    Most young singles don’t have large problems and won’t buy what is a relatively low cost policy. Their attitude is if something acidentally happens the hospital will take care of it and they can’t get “blood out of a stone” so we all pay for their care. Illegals also get “free care” we pay for as do those not insured enough to have their insurance pay for all of their care. Then we have Medicare and Medicaid that are riddled with waste, fraud and abuse that costs us $200 to $700 billion a year that we don’t even discuss.
    Whither a prevledge or right, the fact is that we will all lose the battle while we argue, while either way we all lose as more and more of the costs are picked up by the taxpayers who have no way to control the government!

  20. for a brief second there I fell in love Margalit.
    As much as I would love to see Education be a personal responsibility paid by those who choose to have kids, at a minimum I would like to see all federal spending eliminated. Those tax dollars should never leave the state.
    “Would that apply to a single mother who can’t afford child care?”
    This is where liberals really frost me. I can’t beleive these simple solutions don’t cross your mind. If you have 10,000 single mothers who can’t work becuase they can’t afford day care the Liberal solution is to give them welfare checks and expect nothing in return.
    As a business owner that works for a living the obvious solution is have the mothers work 5 days a week then on the sixth day watch the kids of the other mothers. By each monther watching kids 1 day a week the others are now all free to work. Now they all support themselves, they aren’t sitting around getting knocked up again, and you just lowered my tax burden. Obvious solution the left will never support becuase it won’t buy them any votes or lead to more future voters.

  21. You know well, Peter, that I have advocated “adequate care,” not “equal care.” There can never be “equal care,” if only by virtue of the fact that some providers are more skilled than others. When I look “over there,” I do not like what I see, and I am unimpressed with these grim statistical averages. Here, some people are getting better care than others (and far better than over-there others), but as long as adequate care is assured, I see nothing to get excited about. Like most of Middle America, I just don’t resonate to medical collectivism.
    As for alleged insurer profitabiity, I see you have chosen to ignore my point that employers who have elected to self-insure aren’t saving all that much. They’re hurting too.
    Are you seriously proposing that Medicare reimbursement rates be hammered even lower?
    I don’t understand your objection to means-based Medicaid. We don’t need people in nursing homes at our expense sitting atop handsome portfolios.

  22. Lisa, if you read what I wrote – “Why is education a right?…… Education could be a commodity as well. It’s not in the bill of rights.”, you’ll see that I am not calling it a right. It’s a service, in my opinion. It’s a service provided to children and if the State chooses to force parents to ensure that their children avail themselves of this service, there is not much non Texans can do. You could vote for local folks that have a different opinion.
    Governments, State or Federal, can choose to provide services that are not necessarily enshrined in the bill of rights.

  23. Margalit you keep calling education a “right.” It doesn’t feel like one. Here in Texas parents can be criminally charged and jailed if their children are not in school. Here in Texas the overbearing scepter of the public school system dictates how you spend your family time in the evenings and on weekends, and to a certain degree over summer vacation. Speaking of vacations, your kids better NOT be absent from school for any family events or they will threaten to, or actually will, turn the parents over to the DA for criminal prosecution. Some “right.” It’s a mandate.

  24. “Let them work an extra 8-16 hours a week in exchange for healthcare.”
    Would that apply to a single mother who can’t afford child care? And would that extra work be deducted from their welfare payments? And where would they work? I wonder if the banks did extra work to qualify for our bailout?

  25. “So what happened to the mantra of “equal access”?”
    Not sure what you mean, I’ve always been for equal access, much more equal than insurance companies or yourself want, no pre-existing, no app to fill out, no recissions, that’s how equal access is done in other industrial countries.
    “I’m just opposed to de facto expropriation.”
    Well I’d be for expanded access to Medicare and fold Medicaid into Medicare at Medicare reimbursement rates (how’s that for more equal access), then use that huge public option to negogiate prices/reimbursments to drive down prices – something the insurance industry has never done. Insurance is welcome to compete and carve out their own market.
    Profits never seem to be the issue for any provider, each one will say how little they’re earning (even specialists with several vacation homes and maybe a strip mall), yet healthcare costs continue to rise 6%-10% compounded yearly. I think the remuneration/bonuses of execs, especially “non-profits”, are onscene while pleading low profits and also still able to give their employees yax free cadillac coverage – for free. But insurance has always been willing to take their percentage off an increasing pool of dollars while not doing anything substantive to control costs for their premium payers.
    “I think you may have been a little artful in your example of Medicaid eligibility.”
    Nothing “artful” about it, just the facts here in NC from the DHHS web site.
    “I know of one person with a monthly income of $1,300 who could not qualify for Medicaid, not because of her income, but because of her savings.”
    How does that bolster your argument that Medicaid recipients should be required to spend their assets first – your example proves that Medicaid does require it. How much were her savings?

  26. I pay state taxes for education. I do not believe the feds should be in education at all. They should not be telling the states what to teach. They should not be paying money collected from one state to a different state.
    have a nice weekend

  27. BTW, she may have gotten her ER treatment and maybe also an emergency surgery if needed, but no way she would have gotten PT…..

  28. MD as HELL,
    Call to arms is a bit strong. There is a reason why I keep going back to education. Currently people pay for education whether they have kids or not. Hell they even pay for public education if they send their kids to private schools. Every person that pays taxes shares the burden of public education. It’s buried in your taxation.
    Why is education a right? Surely you can pay for it yourself if you decide to have kids. Maybe you should be responsible and think twice before you have kids knowing that you’d have to pay for 12 years of schooling (Nate will like this). Education could be a commodity as well. It’s not in the bill of rights.
    However, there is no call to arms over the education financing model.
    Health care should be the same – financed by progressive taxation. No need to worry about preexisting conditions at all.
    Just like there are private schools out there, there could also be private insurers. Just like private schools are regulated and required to provide a minimum curriculum, so should private insurers be regulated.
    Just like there are private programs for the gifted, there could be fancy private supplemental insurance plans.
    And remember, this does not imply that physicians and hospitals are owned by the government. Nothing needs to change there.
    So why is health care so much different, that it requires a call to arms? What exactly am I missing here?

  29. Margalit,
    If she were hit by a bus the bus would be paying. She is not sexually active at this time. When she was she was on birth control. Please don’t tell me you really think a person can buy insurance for a pre-existing condition. If that is so, then people should buy life insurance posthumously.
    I guess the tax payors would graciously kick in? Is that not what this bill was all about without being gracious?
    And what is wrong with being optimistic instead of burdened with the “what-ifs” of the handwringers and fretters?
    If she went to the ER she would get the care she needed and make payments for a long time. Better than making payments for a long time and never needing it, if you did not want it. That is the key: if you did not choose to buy it. Being forced to buy in ought to make a real American’s stomach churn. It should be a call to arms.

  30. MD as HELL, optimism is a fine quality, but what would happen if your young lady got hit by a bus when she left your clinic and ended up in the ER and got admitted for a few weeks after which she would need PT for a year and all sorts of follow up and maybe a couple more surgeries?
    Or under happier circumstances, she got pregnant unexpectedly and while celebrating the news, it suddenly dawned on her that having a baby costs a lot of money (maybe a C-section, maybe twins, maybe a little premature, maybe a little time in the NICU….) and it’s kind of late to buy coverage now seeing that her pregnancy is a preexisting condition.
    I guess the taxpayers would graciously kick in, but it would have been nice if she would have participated in the burden while she was able to.

  31. if you leave employer based coverage HIPAA guarantees you the ability to buy individual coverage.
    I liked a lot of what the Dr. said and agree about the responsibility part. The problem is we have removed all of the responsibility for 30-40% of the country. They no longer have a responsibility to contribute and try to support themselves but they have a right to the labor of the rest of us.
    I would have no problem helping people after they have demostrated the fullfillment of their responsibilities. The “solutions” from the left never require any contribution from those seeking, only more from those giving.
    Instead of giving away Medicaid why not require they work for it? Let them work an extra 8-16 hours a week in exchange for healthcare.

  32. So what happened to the mantra of “equal access”? And frankly, Peter, I care little what insurers want. I’m just opposed to de facto expropriation. I further believe “progressive” notions of insurer profitability are outlandish, spread to gull the public into believing that a “public option” will be like manna from heaven.
    I think you may have been a little artful in your example of Medicaid eligibility. I know of one person with a monthly income of $1,300 who could not qualify for Medicaid, not because of her income, but because of her savings. As for the particulars of expanding the “safety net,” I will leave that to the experts. I will be receptive to an reasonable proposal.

  33. I saw a young lady today with no insurance. i sent here to radiology next door for a study. Neither of us turned her away. She will pay her bill, eventually if not now. My bill was around $100. Her study was $275. She was a new patient. She is fine.
    If she has a good year she will not spend another nickel on healthcare this year. She is only 21. Does she really need to be a criminal if she does not have insurance? Does she need to fund Medicare or Medicaid with taxes? She is a youth pastor.
    I prefer anonymity to more patients. We are already well known and even after 12 years we see more new patients than established patients. We are an urgent carel. We also staff the ER.

  34. Nate, regarding preexisting conditions and HIPAA and all that, what happens when you move from a job to buying your own insurance, not another group insurance, just individual insurance?
    In response to your comment, the assumption made by Dr. Schimpff was that health care is a right and therefore carries responsibilities with it. The problem is that if those responsibilities are measured by achievements, it is no longer a right. It becomes a privilege for the gifted. I was just pointing out that the logic is faulty.
    Now, I’m pretty sure you don’t consider health care a right anyway… 🙂

  35. There are some statements that need fact-checking here:
    *We spend more on healthcare than anyone else because we spend more on everything than anyone else.*
    Do you know the cost of living in Japan?
    Do you know that Japan less per capita than the US but a melon still costs twenty dollars in supermarkets? The US *once* had the world’s standard of living. It’s time to update your facts. The US has neither the most prosperous people nor the highest prices in the world so we don’t “spend more than everyone else” in any plausible sense of the phrase.
    High costs generally come from inefficient production and inefficient markets. America has at least moderately efficient markets for cars or electronics and so we in reality don’t pay more than anyone else for these things. In health care, the inefficiencies of production and markets have been exhaustively documented here and elsewhere and results are visible. What more can I say?
    *Congress is not right to try to provide access for all. It is not theirs to give.*
    Congress, meaning the US government, spends approximately as much per capita on health care as Britain – and US consumers *separately* also pay as much per capita as Britain (And this neatly adds up to US health care costs being twice British health care costs). Britain’s national health system is certainly flawed but it is there and provides free access. So Congress, right now, does have the money that could buy the *resources* that would be required for access for all. Of course, – this money wouldn’t buy this access under the American strictures but it is demonstrably false that Congress doesn’t have the *resource* to provide access for access. American strictures, clearly, are what are holding things back. Congress can change those too but that might impact various well-heeled groups.
    *I am here right now and anyone can come in. My clinic is not free but it is not expensive.*
    Uh, You know you are unusual, right? I have been turned away from clinics for not having insurance, regardless of my ability to pay.
    In Portland Oregon, five years ago, there was only one for-profit clinic that would see uninsured patients *with the ability to pay* – that’s one clinic for a city of a million people. A skin care specialist I tried to contact would not see patients without insurance, again, regardless of my ability to pay. In fact, my health care experience has involved pay private insurance $200+/month for insurance that got me only … the ability to pay for services out of my own pocket!
    I’m surprised you don’t link to your web site. If your clinic accepts the uninsured, I imagine you could do a brisk business.

  36. archon41, are you speaking of the dead health bill? If you are what was homogenized about it? VA, Medicare, Medicaid, pools, employment coverage, individual, and of course the dead public option, a success for insurance. Of course insurance wanted subsidies, which did nothing about rising costs, but kept their income, profits and bonuses intact. So what subsidy at what levels of income would you propose and would the taxpayer/deficit just keep adding subsidies as costs/premiums kept rising?

  37. So why don’t we concentrate on expanding eligibility there, Peter, instead of leaping into homogenized health care?

  38. “So. . . access to Medicaid is not “access to care”? Or do you perchance have in mind those who can’t qualify for Medicaid because of their assets, and are reluctant to apply those assets to their own medical care?”
    What assets? I link a Medicaid eligibility chart for NC. Family of 4 can’t exceed just under $600 per month and $3000 in resources. You might want to look at the % of poverty level qualifications as well. Obviously these people don’t have access to company plans but would be part of the individual market. Maybe you could quote a health plan for a family of four. archon41, would it be that you have one of those tax free company paid “cadillac plans”?
    http://www.dhhs.state.nc.us/dma/medicaid/basicmedelig.pdf

  39. Yes, but, under COBRA, you have to pay the employer’s part of the premium–serious money. Looks like someone else ought to pick that up.

  40. “All too many individuals find that they are denied coverage because of a preexisting condition when they move from one job to another”
    Dr. this is inaccurate, HIPAA already eliminated pre-ex when you move from one job to another unless you go more then two months without coverage, in which case this is remeded by the responsibility to have insurance not eliminating the right to apply pre-ex to those that break the rules.
    Margalit if your inner liberal can stop spinning for a sec you would see that those that don’t study and go to school don’t get the education and the educaiton system kicks them out, unlike our healthcare system if you don’t take advantage of the opprotunity when your suppose to you lose it. If healthcare and education where in fact similar if you didn’t take care of yourself and maintain your health when you condition exploded it would not be treated. They don’t allow 20 year olds in Kindergarden. They shouldn’t allow non compliant what ever in free health care.

  41. So. . . access to Medicaid is not “access to care”? Or do you perchance have in mind those who can’t qualify for Medicaid because of their assets, and are reluctant to apply those assets to their own medical care? You want me to fund their lifestyle? Because that’s the way they do it “over there”?

  42. Congress is not right to try to provide access for all. It is not theirs to give.
    It does not take a physician to eat right and exercise right and keep your weight down. It does not take a coach, either.
    We spend more on healthcare than anyone else because we spend more on everything than anyone else.
    Our results are no better because much of our spending is not for healthcare, but for attention. We spend a fortune telling the worried well they are well. We don’t even try to tell them they are too worried, bacause they will sue if they happen to have something.
    Everyone has access to care. I am here right now and anyone can come in. My clinic is not free but it is not expensive. It is worth it if you need to be seen. Too many people want to be seen, but they want it to be free.
    Nothing is free. Not even in Healthy Howard.
    Health care is not a right, not a privelege and not a responsibility. It is a commodity. Do you want to guarantee all have access to gasoline?

  43. “In another pairing of rights with responsibilities, commercial insurers and Medicare should be able to incent patients to hold down costs with premium reductions for those who do have an appropriate weight, do exercise, do not smoke, do get their vaccinations and do have screenings done.”
    Just so I understand this better, let me make an analogy to education, which is also a right in a similar sense. So extending this line of reasoning, would you say that “free” education should be available only to those that get appropriate grades in school (appropriate weight), those who do homework (exercise), those who do not copy homework (do not smoke), etc…..?
    Maybe we should make children that are “not so bright” pay for kindergarten or high school or special education services?
    Maybe education should only be available to children with a certain genetic/environmental IQ, and not others?
    We can, and should, encourage children to study hard and people to take care of their health, but in a free society, that is about as far as we can go without losing something far more precious than our transitory health.

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