OP-ED

American Healthcare X

“A decent provision for the poor is the true test of civilization.”
~Samuel Johnson

“Joe” has been on the streets now for two months. He’s 35, unmarried, and diagnosed with chronic schizophrenia since age 19. His illness is difficult to manage, even with regular medication, and Joe is subject to hallucinations telling him to “fight off the evil ones”. Like most people with psychiatric disorders, Joe has never been violent—but when his illness is not well-controlled, he can become loud and belligerent.

Despite his many tries at holding down a job, the economic downturn and his worsening psychosis have left Joe jobless and homeless.  Joe’s family thinks he is “faking” his symptoms and they are “fed up” with him. They have refused to take him in or help him with his medical care. Joe has no friends willing to help him and survives on the streets by panhandling and dropping in at soup kitchens. The local shelters won’t accept Joe, because he is “too agitated.” Joe sleeps in alleyways, or, when lucky, in ATM stations. In the past month, he’s been beaten up twice by members of youth gangs.  Recently,  Joe was diagnosed with type 2 diabetes, requiring daily medication and monitoring. Joe says he doesn’t want “charity”, and would like to work again, but doesn’t see how he can.

“Joe” represents many patients I’ve cared for during nearly 30 years of medical practice, and typifies thousands of Americans with severe mental illness.   In my previous blog entitled, “The Libertarian Mind”, I posed this question: what is the moral responsibility of federal and state government to help care for people like Joe? I argued that the Libertarian Party platform—calling for the abolition of “the entire social welfare system”, including food stamps—is neither humane nor compassionate.

And, I argued in favor of a publicly-funded, single-payer insurance system, as advocated by PNHP (Physicians for a National Health Plan).  Although a few readers wrote in support of my position, many (mostly anonymous) commentators were very critical. Nobody who wrote in really answered my question directly. I’d now like to address some of the criticisms of my piece, as well as to debunk some myths surrounding the history of the health care in this country. First, though, I need to sketch the general health care picture in the U.S. today.

Many commentators of all political stripes would agree that the U.S. health care system is in deep trouble. Despite our tremendous progress in medical research and technological innovation, our health care system is not “delivering” to those who need it most: the very poor and sick, whose friends, family, or community cannot or will not help them. Far from having “the best health care system in the world”—as some politicians have claimed—our system is failing in the most basic measures of medical care. This is not for lack of spending. As Victor Fuchs PhD, of Stanford University recently wrote in the New England Journal of Medicine (Dec. 2, 2010), the U.S. government “…currently spends more per capita for health care than eight European countries spend from all sources on health care. Though life expectancy is far from a perfect measure of the quality of care…life expectancy at birth in every one of these eight countries is higher than that in the U.S.”  And, in a recent Commonwealth Fund-supported study comparing “preventable deaths” in 19 industrialized countries, researchers found that the United States placed last.

The huge amount of money spent on administrative costs in the U.S. –rather than on direct care—is a major factor in these disparities. At the same time, mental health care is badly under-funded, even allowing for the recent recession. More and more of the burden of caring for the destitute and homeless with mental illness is falling on our police force. As the New York Times recently reported (Dec. 5, 2010), “A lot of people view calling the police  as the only way to get loved ones any kind of treatment…” with the result that “…many patients who need a doctor get a law officer instead.”  People like Joe are barely able to scrape by in the best of times, with the aid of state and federally-funded programs like Medicaid. Abolishing such programs, as the Libertarian Party advocates, would likely be a death sentence for thousands of people like Joe.

But the prospect of such deaths does not seem to trouble some individuals who proclaim a “libertarian” ideology. One person who wrote to criticize my previous blog argued that  “…Libertarianism accepts that life happens and some people will live less fulfilling lives and die early, but overall, everyone will live better…” Furthermore, this reader argued that the voluntary efforts of private groups and individuals have been far more reliable than government aid, pointing to the government’s response during Hurricane Katrina. This same reader also worried what would happen in a “liberal utopia” when “government support doesn’t materialize.” Let’s leave aside the question of how many more people would have died during Katrina, had the federal government not intervened, and consider this reader’s basic premise: it’s sad when some people die of starvation and neglect, but, hey—that’s life. It’s all in the service of the greater good. Presumably—and in an indirect response to my question—this reader believes that the federal and state government owes nothing to the destitute sick and hungry, even when their family and friends have deserted them. I was wrong, in my first article, to characterize such an attitude as one of “narcissism.” The correct term is “depraved indifference.”  Now, I happen to believe that this particular reader, like most Americans, would “do the right thing” for someone like Joe. In general, I find that most people are better than some of their cockamamie theories. But the savage irony of   libertarianism is that it pretends to honor the individual, while actually viewing any particular individual as a potential pawn—readily sacrificed in the name of the greater good.  Libertarians are welcome to this predacious view of “governance”. I for one would not wish it on a pack of jackals.

As for that “liberal utopia”— “utopia” literally means, “no place”–it is striking that no place on earth has ever demonstrated that a purely libertarian form of governance can succeed, much less provide adequate health care for the destitute sick. I am not a political philosopher, but I consider caring for the destitute sick a profoundly conservative act. It conserves the most precious resource we have—our fellow citizens—and helps them return to health, work, and productivity.  I am not talking about “charity” for someone like Joe—I am talking about food, shelter, and health care.  I’m talking about a vocational rehabilitation program to help Joe get back into the work force.

Some self-described libertarians argue that a government that finances such services may eventually go bankrupt. I say that a government that shirks its obligations to the destitute poor is morally bankrupt and deserves no support from its citizens.  When we pass by a river and see someone drowning, we take it upon ourselves to throw that person a life preserver. We do not protest, “But I might wrench my shoulder, if I have to do this three or four more times today!” Governments are not abstractions: they are collections of individuals. I do not want to hold government in the aggregate to a lower moral standard than the one I expect of individuals. The hypothetical fear of “bankruptcy” does not negate the government’s moral duty to protect the health and safety of its most vulnerable citizens.

Another critic of my first essay asked plaintively that we remember America during its “first 150 years” of existence. “Remember that America?” he wrote. “The land of the free? The land of opportunity? You ask for evidence that families, friends, churches, communities, and charity organizations would be enough to support the needs of society, discounting the fact that we successfully existed on such a system for the majority of our nation’s existence.”

Ah, yes—I do remember. I saw that America portrayed on an old TV show called “The Waltons”, in which a tough, decent family used to take in needy strangers during the worst years of the Great Depression. Perhaps the commentator I’m quoting would act in the same, decent manner.  But there is little in the history of American health care that accords with that Hollywood script. (By the way, as regards “the land of the free” and “the land of opportunity”: did the writer forget that until 1865, 4 million black Americans were in chains? And that women did not get the vote until 1920?).

For most of the 18th century, prior to the rise of “poor houses” in this country, many paupers who could not secure family or community support were auctioned off like cattle. They were actually sold to the lowest bidder–the person who would agree to provide room and board for the lowest price—and effectively became indentured servants (see http://www.poorhousestory.com).

Prior to the Social Security Act of 1935, and for much of the 18th and 19th centuries,

“…most poverty relief was provided in the almshouses and poorhouses. Relief was made as unpleasant as possible in order to “discourage” dependency. Those receiving relief could lose their personal property, the right to vote, the right to move, and in some cases were required to wear a large “P” on their clothing to announce their status.” [http://www.ssa.gov/history/briefhistory3.html].

As for the destitute sick who lacked families to care for them, for much of the 19th century, they were dependent largely on “charity hospitals”, supported by generous donors, in which doctors provided care free of charge. This might seem to support the claim that we “successfully existed” with a charity-based system of health care. Unfortunately, charity hospitals were subject to the whims and means of their donors. For example, the Boston Lying-in Hospital (later, Brigham and Women’s Hospital) provided free care for indigent women, but had to close in 1856 because it could not meet expenses. It was not able to re-open until 1873. In our own time, similar financial problems forced closure of New Orleans’ famed “Charity Hospital” after Hurricane Katrina—an institution that cared for tens of thousands of the uninsured sick.  In such circumstances, do we really want to say that the state and federal government have no obligations whatsoever, and no right to raise any revenues in behalf of the destitute sick?

As a nation, we can and must do better. There are feasible economic plans, described on PNHP website, that will allow us to provide basic health care to all Americans, without breaking the bank. “Joe” is not a lazy, ne’er-do-well, nor are the thousands like him in this country. Joe is your neighbor, your friend, or your cousin. More important: Joe is your brother.

References and readings

Victor R. Fuchs: Government payment for health care—causes and consequences. New England Journal of Medicine, Dec. 2, 2010.

Ellen Nolte, Ph.D, C. Martin McKee, M.D “Measuring the Health of Nations: Updating an Earlier Analysis” (Health Affairs, Jan./Feb. 2008),.e

Katie Zezima: State cuts put officers on front lines of mental care. New York Times, Dec. 5, 2010.

Boston Lying-in Hospital. Records, 1855–1983. Francis A. Countway Library of Medicine. Accessed at: http://oasis.lib.harvard.edu/oasis/deliver/~med00056

Judith W. Leavitt , Ronald L. Numbers:  Sickness and Health in America: Readings in the History of Medicine and Public Health. University of Wisconsin Press, 1997.

Pies R: Health Care is a Human Rights Issue. Psychiatric Times. Nov. 15, 2010. Accessible at: http://www.pnhp.org/news/2010/november/health-care-is-a-human-rights-issue

Single-Payer FAQ: Physicians for a National Health Program. Accessed at: http://www.pnhp.org/facts/single-payer-faq#costs_down

Libertarian Party Platform, 2010. Accessed at: http://www.lp.org/platform

Ronald Pies, MD, is Professor of Psychiatry and Lecturer on Bioethics at SUNY Upstate Medical University; and Clinical Professor of Psychiatry at Tufts University School of Medicine. He is the author of several books on comparative religious ethics, including Becoming a Mensch (Hamilton Books). Dr. Pies reports no financial arrangements or professional affiliations with any political party.

Livongo’s Post Ad Banner 728*90

Categories: OP-ED

Tagged as: , ,

29
Leave a Reply

28 Comment threads
1 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
15 Comment authors
yoga For weight lossRichard KahnNate OgdenAl KennedyPaolo Recent comment authors
newest oldest most voted
yoga For weight loss
Guest

Remarkable issues here. I’m very happy to look your article.
Thank you a lot and I’m having a look forward to contact you.
Will you kindly drop me a e-mail?

For an awesome solution please take a look at this amazing
site; yoga For weight loss

Ronald Pies MD
Guest
Ronald Pies MD

I have appreciated the chance to post my views here, and I hope that all THCB readers–whatever their point of view on health care–have a pleasant holiday!–Regards, Ron Pies MD

Nate Ogden
Guest
Nate Ogden

“Readers who truly want to examine “actual results”, rather than abstract theories,” And how do you scientifically measure happiness and health? A kid from a wealthy family is happy when they get a new DS, a kid in poverty is happy when there is no shootings for a week, these polls, they are nothing more, are scientifically worthless. “–I developed quite the case of the giggles after reading that!).” So it was the giggles that prevented you from any meaningful responce? I’ll rememeber that next time I can’t support an argument or back up a claim, it was the giggles… Read more »

DeterminedMD
Guest
DeterminedMD

So, I lack courage and personal responsibility by not putting my name on my comments.
Bit of a projective comment on your part, eh, Doctor?
I will enjoy your break from this blog. Thanks for your part of the mob mentality.
Signed, board certified physician in the United States

Ronald Pies MD
Guest
Ronald Pies MD

Readers who truly want to examine “actual results”, rather than abstract theories, should closely inspect Unicef’s recent report on children’s health, safety, and well-being in various wealthy countries [www.unicef.org/media/files/ChildPovertyReport.pdf]. The Unicef findings clearly show that, in general, countries with the most progressive national health and welfare systems (like Denmark and the Netherlands) foster the healthiest and happiest children. The country that most closely approximates a “libertarian” or “free market” approach–the U.S.–is among the worst performers, when it comes to children’s health, safety and happiness. (As for the notion that the real killers in this country are “liberal” programs like Medicaid… Read more »

Nate Ogden
Guest
Nate Ogden

The public programs also weaken the family, if people were more dependent on their family I don’t think we would have so many broken homes. Kids don’t need their parents the government will feed and house them. Then when the parents get old the kids have their own life and let the government take care of their paretns. Medicare is just one example of government trying to solve a problem that didn’t exist and failing instead of addressing the small problem that did exist and actually doing something productive. Most government programs suffer the same grandious objective with no or… Read more »

Mary Ritenour
Guest
Mary Ritenour

If I may, two points from my personal experience with the public “safety net” that I believe are relevant. During the lowest point, I was, as a single mom, supporting 4 children ages 12 and under. My income barely provided us with housing and food. I reached out to the local school in the hopes that my kids could take advantage of a free lunch program and ease the strain on our finances. After a lengthy application process I was told that my family did not qualify for the program because my income was $21 a month TOO HIGH. Publicly… Read more »

DeterminedMD
Guest
DeterminedMD

As a fellow jewish person, if Dr Pies was raised the way I know I was, we instinctively both from our religion and our oath as physicians want to give and preserve a healthy community. But, what has probably corrupted his thinking is this overtolerance of liberalism I have come to realize has failed the public. How can you as a doctor not step back and see the overt pratfalls of single payor systems? And let politicians dictate the pace? You were trained in an era that guarded outside interferences much better than what I was taught years later. Was… Read more »

Nate Ogden
Guest
Nate Ogden

“To be sure: the U.S. did not do badly—overall, we were tied for third place. However, as you’ll see, many countries exceeded the U.S. in % of the population giving money to charities.” Remove those self described as liberal and see how our score sky rockets, countless stuides have shown a distinct portion of the population that only engages in charity when it is giving away someone elses money, sadly they bring down the score for the entire country when compared that way. ” and the callous indifference to the most vulnerable members of our society, reflected in the Libertarian… Read more »

Richard Kahn
Guest

As Nate Ogden points out above, Dr. Pies evaluates intent and not actual results. And I would hardly point to UNICEF as a guide. It is very hard to find any examples where libertarianism in health care and social services in industrialized nations because they do not exist. However we do see as examples in every country that has these “social safety nets” the net actually serves to trap the individual as nets are designed to do. As DeterminedMD points out below, “meaning well does not infer you will do well” is quite appropriate. But “a man convinced against his… Read more »

Mary Ritenour
Guest
Mary Ritenour

Dr Pies, thanks for your response. I am aware of those problems and and am part of my community’s efforts to alleviate and assist those who are struggling. My question was more toward the triggering event(s) that caused the fervor of your posts – some precipitating event? In any case, there are “safety nets” in place, but like all nets, there are holes. I have, myself, fallen through those holes, but had friends and family that offered support and encouragement, and I was able to pull myself and my children up out of poverty. While it is important that we… Read more »

Ronald Pies MD
Guest
Ronald Pies MD

Dear Ms. Ritenour: Thank you for taking the time and effort to write. I do understand that there are many ways one can calculate charitable giving, and certainly a “total volume” measure of a country’s charity is one way. That means that if a country has a million people in it who give one dollar per year, it will far exceed the “generosity” of a country with 10,000 people in it, each of whom gives $50. To me, this seems an odd way of looking at the personal generosity of any particular group of citizens. If you are not persuaded… Read more »

Mary Ritenour
Guest
Mary Ritenour

Dr. Pies, The Wikipedia source you mentioned specifically describes Official Development Assistance (defined in the article) and Humanitarian Aid, as defined by GHA who interestingly comments that tracking and reporting on Humanitarian aid is problematic due to the self-reporting nature of the process. They warn specifically about comparing donors because of the incompleteness of the data. They also are looking at governmental aid/donors, citing specifically: “Local communities and families, national and local government, civil society and the private sector almost always prove the most immediate deliverers of humanitarian aid. No analysis of resources for humanitarian assistance can be complete without… Read more »

Al Kennedy
Guest

Interesting Blog, even though this was not what i was looking for (I am in search of clinics like this one> http://www.ccsviclinic.ca/ )… I certainly plan on visiting again! By the way, if anyone knows of a good clinic that does CCSVI Screenings? BTW..thanks a lot and i will bookmark your article: American Healthcare X…

DeterminedMD
Guest
DeterminedMD

Wonderful, play the numbers game many of the commenters here do to displace and deflect from the real issue here: instead of problem solving the biopsychosocial dilemmas that drive the health care crisis, focus rather on political party lines, here one you espouse as pure liberal, if not socialistic philosophy that equally fails what your opponents preach as conservative insensitivity, and just repeat the rhetorical nonsense that is extreme political bents of 2010. I don’t get why you post here. Is this what I have to look forward to as I age, that wisdom is a given just because one… Read more »

Ronald Pies MD
Guest
Ronald Pies MD

Thanks to Dr. Craig Vickstrom, Mary Ritenour and others for their comments. Of course, I agree with Dr. Vickstrom that “Libertarianism is a failure in the provision of essential services”, at least as formulated on the Libertarian Party (LP) website. To be sure, there are many “stripes” of libertarianism, but if the LP social agenda were ever carried out (God forbid!), the sickest and poorest among us would literally be dying in the streets. I must correct a popular–and, in my mind, self-comforting– myth that Ms. Ritenour repeats here; i.e., namely, that “Americans lead the world in private charitable giving.”… Read more »