Monday, August 27, 2012

The unpredictable risk and benefit of Medicare vouchers

Trying to figure out whether Medicare vouchers are a good idea for patients and their physicians?  Then consider these two basic questions:

  1.  How much will the federal government contribute?
  2.  Who is at risk for health care cost increases?

How much will the government contribute?  The traditional Medicare program has no set limit on how much the federal government will contribute to a beneficiary’s health care, although there are limits on how much it will pay doctors and hospitals.  That’s what makes it an open-ended entitlement.  Medicare vouchers (or premium support, if you prefer) place an annual limit on how much the federal government will contribute, and anything above that comes out of the beneficiary’s own pocket.  As such, Medicare would no longer be an open-ended entitlement, but a defined contribution program.

One can imagine a voucher that would be so generous that beneficiaries could buy even more coverage than they have today under the traditional program.  But that would defeat the purpose of vouchers, which is to drive down costs.  So by necessity, the federal voucher contribution has to start out by being less per person than the government is now spending on traditional Medicare, or it won’t save money, right? 

And no matter where the initial dollar amount is initially set—let’s assume that it would start out being pretty generous, good enough to buy a health plan that offers benefits comparable to traditional Medicare--the government would have to decide how much it would be allowed to go up each year:  enough to keep pace with rising health care costs or less than that?  If the federal contribution doesn’t keep up with average costs of the benefits covered by Medicare, beneficiaries would pay more, but the government saves more; if it keeps pace with average costs, the government saves less but beneficiaries pay less. 

Voucher advocates say that the cost-savings will principally come from competition among competing health plans, and if so, seniors wouldn’t necessarily have to pay much more than they do today and the government would still save money.   Beneficiaries will have an incentive to choose a health plan that offers coverage at a premium that is not much more than the voucher amount.  Insurers will have an incentive to keep costs close to the voucher amount or risk being priced out of the market. 

The theory sounds good—but let’s look at who is really at risk for keeping costs down under a Medicare voucher system (hint: it isn’t the government).

Who is at risk?   Competition between health plans and traditional Medicare will only be successful in driving down costs if the competing health plans can use their market power to change the behavior of patients, physicians and hospital.    That’s because health plans (except for ones attached to physician group practices and hospitals) don’t really deliver care, they pay for it, through contracts with physicians and hospitals.

In a voucher system, competing health plans will try to drive down those costs by leaning on patients and “providers” to lower costs.  They might pay clinicians and hospitals less, hire less expensive mid-level providers, restrict patients to an approved network of providers, pay their network “providers” based on performance (lower costs, and one hopes, also better outcomes) rather than volume, deny claims for services, demand lower rates from drug companies and device manufacturers, require that Medicare patients enrolled in their plans pay more out-of-pocket, and place limits on benefits (to the extent that they are allowed to by the government). 

The better and more innovative plans might try to organize care better to achieve improved outcomes more efficiently, through models like Patient-Centered Medical Homes. 

So to a great extent, under a voucher system, it’s the physicians and hospitals who will be at risk for cost increases, because to be successful in keeping their premium costs competitive, the insurers would have to get the “providers” and “suppliers” of care to charge less and deliver services more efficiently

Health plans that are integrated with physician group practices and hospitals would likely have a competitive advantage under a voucher system because they can “organize” their providers more effectively than traditional insurers that contract with individual physicians and hospitals on an a la carte basis.   Vouchers, then, might accelerate the trend to hospital-physician-insurer consolidation, at the expense of physicians in independent practice.

But patients enrolled in Medicare would be the ones at the greatest financial risk: either because they would get fewer benefits and have to pay more out of pocket for the less costly plans that the voucher amount would (mostly) cover, or because the federal contribution falls short of the cost of the premiums charged by the competing plans, with the difference made up by them. A new study by the liberal-leaning Center for American Progress Action Fund, based on the Congressional Budget Office’s analysis of the most recent version of Rep. Ryan’s Medicare premium support proposal, concluded that if competition doesn’t lower costs enough, the voucher contribution would not keep pace with rising costs—and the result would to vastly increase beneficiaries' average health care bills over their retirement years:  

--For seniors reaching age 65 in 2023 by $32,900
--For seniors reaching age 66 in 2030 by $73,600
--For seniors reaching age 67 in 2040 by $139,100
--For seniors reaching age 67 in 2050 by $225,200

I am sure that voucher advocates will take issue with those estimates, because the Center assumes that competition between health plans—and, more to the point, health plans’ ability to drive savings out of the “providers” and suppliers of health care-- won’t be effective in slowing cost increases, so beneficiaries will be left holding the bag between the capped federal contribution and the average premiums.    

Neither voucher advocates nor voucher critics really know for sure, since this is uncharted territory—there is no actual real-life experience with instituting a voucher system on a large scale basis for people who, by definition, are older and need more health care.  Competition might be enough, but if it isn’t, the cost-shift to seniors would put affordable health care out of reach for many, if not most of them.

Given the uncertain benefits and risks of vouchers, wouldn’t it make more sense to first pilot test a premium support system, as the American College of Physicians has recommended in a recent position paper, before adopting it as national policy?  This is how ACP puts it:

 “It is vitally important that a premium support model be tested to determine possible adverse effects or unintended consequences. Particular attention should be given to such issues as enrollee and provider reaction, plan participation, market effects, premium levels, and barriers to care. If done properly, a defined benefit voucher program may encourage beneficiaries to select coordinated care plans that may promote preventive care, wellness, and better cooperation among physicians and other health providers. However, caution should be exercised prior to implementing such a significant change in Medicare financing that will affect millions of the nation’s elderly and most vulnerable citizens.”

A pilot-test, in other words, would be the sensible, even conservative approach to resolving the voucher controversy, because it would allow us to learn from real-life experience how premium support might be designed and work in practice, and what its effects are on patients and physicians, rather than embracing or rejecting vouchers based on unproven ideology, beliefs, conjecture and assumptions.

Today’s questions: Who do you thinks bears the greatest risk under a Medicare voucher system?  Do you agree with ACP that it should be pilot-tested first before a decision is made on its adoption?

Tuesday, August 21, 2012

Medicare and the Triumph of Nonsense over Substance

Medicare has suddenly become a centerpiece issue in the 2012 election—but not in a good way.  Instead of an informed debate about Medicare’s present and future place in our health care system, the politicians have subjected us to a daily assault of nonsense over substance:

Let’s start with the nonsense accusation by Governor Romney that "There's only one president that I know of in history that robbed Medicare, $716 billion to pay for a new risky program of his own that we call Obamacare.” This charge has been discredited by independent fact-checkers. 

“The only element of truth here is that the health care law seeks to reduce future Medicare spending, and the tally of those cost reductions over the next 10 years is $716 billion,” Politifact wrote about Mr. Romney’s charge. “The money wasn’t ‘robbed,’ however, and other presidents have made similar reductions to the Medicare program. We rate this statement Mostly False.” 

CNN’s Soledad O’Brien, citing the Congressional Budget Office,, AARP, and the statutory language in the Affordable Care Act itself, discredited a similar accusation by former NH governor and Romney supporter John Sunnunu

There also is the inconvenient fact that Rep. Paul Ryan, Romney’s running mate, included the same $716 billion in Medicare savings in the House-passed budget plan, although Mr. Romney has vowed to “restore” them.   

Here are the substantive facts behind the charges and counter-charges.

It’s true that the ACA makes changes in Medicare payment policies that the CBO estimates will slow Medicare cost increases by $716 billion over the next decade.  (In other words, Medicare’s costs will still increase, but by a lesser amount.)   The Medicare savings come from reducing payments to hospitals, Medicare Advantage plans, and some other non-physician providers. (The ACA did not include any new payment cuts to doctors—rather, it temporarily increases Medicare and Medicaid payments to primary care physicians—but it also did not cancel out scheduled cuts from Medicare’s SGR formula, enacted in 1997.)  

But instead of taking money “out” of Medicare, the ACA actually shores up the Medicare Part A Trust Fund, extending Medicare solvency by eight years, according to Medicare’s actuaries.  Without the ACA’s $716 billion in savings, Medicare would go belly up in 2016 instead of 2024.

How can this be so?  Well, the Medicare Part A Trust Fund consists of the dollars that are collected from payroll taxes to pay for current and future hospital-related health care expenses.  If Medicare pays the hospitals less, the money in the Trust Fund is drawn down less slowly and it lasts longer—just as if a cut in tuition costs would allow the savings you have set aside for your kids’ college education to last longer.   

One could certainly make a substantive argument that the way that the ACA (and Rep. Ryan’s budget for that matter, since it includes the same savings) lowers future Medicare costs increases is unwise, because the cuts in payments to hospitals and Medicare Advantage might cause future access problems.  Or one could make the substantive counter-argument that lowering Medicare payments to hospitals and Medicare Advantages plans is necessary and appropriate--and a better way to achieve savings and efficiencies without harming beneficiaries--than cutting benefits. 

One could also have a substantive argument over whether the Medicare savings, if they are to be kept, should be used to finance tax cuts and help lower the deficit, as the Ryan budget proposes to do, or to expand access to the uninsured and improve Medicare benefits (no cost preventive services, phase out of the Medicare Part D donut hole) as the ACA would do.

But such substance is lost when politicians blithely try to scare seniors into believing that benefits are being stolen from Medicare to pay for Obamacare, when the facts show the ACA actually improves Medicare benefits and extends the program’s solvency by almost a decade.

Which brings me to another nonsense accusation—this one from the Obama camp--which is that seniors will pay $6,000 more under the Romney/Ryan Medicare premium support plan, compared to the current Medicare program.  

The journalists at the site report that this is “outdated” claim based on CBO estimate of an earlier version of Rep. Ryan’s premium support proposal, which would have capped the federal government’s premium contributions at a much lower rate of increase than Rep. Ryan’s current plan.  “[The earlier] plan had the premium-support payments, or subsidies, growing with the rate of inflation, and health care costs have risen much faster than that for years” they write, but “Under the new Ryan plan, that premium-support payment would be tied to the second-cheapest health care plan, which can’t grow more than gross domestic product plus 0.5 percentage points. So, Ryan’s plan says the premium support would always be enough to cover the two cheapest plans.”   Plus, the Ryan premium support plan wouldn’t apply to anyone who today is 55 or older, so it is misleading to scare current seniors into believing that they will pay $6000 more for their Medicare. 

But www.Politifact says that it is “mostly true” that Mitt Romney and Paul Ryan want to convert Medicare into a voucher program—just not now, not for current seniors, but for future beneficiaries starting ten years from now!

Again, there are important substantive arguments that could be made about the wisdom of eventually turning Medicare into a voucher program.  Will limiting how much the federal government contributes to Medicare stimulate cost-savings through competition among insurance plans, or result in cost-shifting to seniors who can’t afford to pay more? Is market competition more effective than the ACA’s approach of squeezing payments and piloting new models of delivery and payment?  Will insurance companies under a voucher system be more or less bureaucratic and transparent than the traditional government-administered Medicare program?  And if Medicare premium support is such a good idea, as Mr. Romney and Ryan maintain, why wait ten years to institute it?  (Read more about my thoughts about the potential impact of Medicare vouchers on my wife’s future Medicare, and the secret truth about vouchers that neither party will admit.)

And, speaking of substantive questions, I would ask Mr. Romney, if the $716 billion in Medicare savings from the ACA is to be restored, as you have promised, and Medicare vouchers won’t be implemented for another decade, as you have also promised, then how do you propose that Medicare cost increases be slowed in the meantime to sustain the program’s solvency and reduce its crushing contribution to the deficit? 

And I would ask President Obama, if the ACA’s $716 billion in savings are to be kept, along with the rest of the ACA, and you rule out vouchers as an option, what else should be done to sustain Medicare’s long term solvency and reduce its crushing contribution to the deficit, since the current level of savings is clearly not going to be enough?

Because, as the National Journal’s Margot Sanger-Katz reports, both the Obama and the Romney Medicare plans fail to solve the cost problem.  “Although they won’t admit it, Romney and Obama have pretty similar visions for how much they think Medicare spending should grow in the future” she writes. “Both have backed plans that would cap per-capita spending at about the same rate, though they would use vastly different means to do so. Neither would come close to eliminating Medicare’s projected long-term deficits.”

She hits the nail on the head. How to eliminate Medicare’s projected long-term deficits is one of the most important substantive issues that should be debated by the candidates, but isn’t, since they are too busy trying to discredit each other while reassuring seniors that nothing must change.   Unfortunately, the Medi-scare nonsense being spewed by them will make it even harder to later get the public on board with the tough choices that will need to be made to sustain Medicare while reducing the public debt, which inevitably will involve a combination of reduced benefits, increased cost-sharing, tax increases, and changes in the way that hospitals and physicians are paid.

Today’s question: Do you agree that the Medicare debate in this election has mostly been a triumph of nonsense over substance?

Tuesday, August 14, 2012

The secret truth about health care vouchers

Which of the candidates for President proposes to give people a defined amount of federal money (call it a voucher) to buy coverage from competing qualified private insurers (under federal benefit mandates) offered through a health insurance marketplace run by government?

The answer: Mr. Romney, and his new running mate, Paul Ryan. And President Obama. 

How is that, you say?  Isn’t the Romney/Ryan vision of how to reform health care diametrically opposed to that of Obama?  Yes . . . and no.

Romney and Ryan both propose to convert Medicare from an open-ended, defined benefit program to a defined contribution, which means that the government would give seniors:
-- a defined amount of federal money (call it a voucher),
-- to buy coverage from competing private health insurers,
--all of which would be required to offer at least the current Medicare benefits,
--sold through a federally-run health care marketplace.

Democrats say that the proposal is a radical plan to “end Medicare as we know it.”

So Republicans are for vouchers and Democrats are against them, right?  Not so fast.

President Obama’s Affordable Care Act would extend health insurance coverage to about 16 million uninsured Americans (with incomes from 133 to 400% of the federal poverty level) through subsidized private insurance offered through exchanges.  This means that the government would give them:
--a defined amount of federal money (call it a voucher, or a subsidy),
--to buy coverage from competing private health insurers,
--all of which would be required to offer a federally-defined level of benefits,
--through a state (or federally-operated) health care marketplace (exchange).

(You might also recall that when Mitt Romney was governor of Massachusetts, he signed into law a program—considered by most to be the pre-cursor to Obamacare—that similarly gives vouchers to help uninsured people buy private health insurance through a state-run marketplace.)

Nevertheless, Republicans say that the Obama’s plan calls for a “radical . .. . health care take-over” by the government.

So let’s get this straight: when Republicans propose vouchers, it is a radical scheme to end a widely popular program (Medicare); when Democrats propose them, it is a radical and unpopular scheme by the government to take-over health care (except when the Republican nominee did it for his own state)!

Go figure.

That’s not the only place where the GOP and the Democrats may have more in common than either admits.  The Washington Post’s Ezra Klein points out the Paul Ryan’s budget plan would keep the ACA’s $700 billion in Medicare cuts that the Republicans say Obama is “stealing” from Medicare (although they have no plans to give the money back to seniors). The difference is that Ryan’s budget would use $700 billion for tax cuts and deficit reduction, Obama uses it to help fund coverage for the uninsured. The Ryan budget and President Obama’s budget both allow Medicare spending to grow by exactly the same amount: the gross domestic product plus O.5%!

This isn’t to say that there aren’t big differences between Romney/Ryan and Obama.  They disagree on  how to restrain future Medicare growth.  As Klein explains, “Democrats believe the best way to reform Medicare is to leave the program intact but vastly strengthen its ability to pay for quality. Republicans believe the best way to reform Medicare is to fracture the system between private plans and traditional Medicare and let competition do its work.  It’s worth saying there’s no particularly good evidence for either option.”

And there is a difference between proposing vouchers to limit how much the federal government spends on an existing health care entitlement (Medicare), as Romney/Ryan propose, and using vouchers to create a new health care entitlement program (ACA), as Obama advocates. One is a partial takeaway of existing benefit guarantees for tens of millions of seniors, the other is a partial expansion of health benefit guarantees to tens of millions uninsured persons.

On Medicare, Romney and Ryan would convert Medicaid to a block grant while cutting federal contributions, saving the federal government many trillions while resulting in 27 million more uninsured (low-income) persons.  Obama’s Affordable Care Act will add up to 17 million more persons to Medicaid, paid for almost entirely by the federal government.

The Ryan budget also would dramatically reduce federal spending on non-defense discretionary programs, with the liberal think tank Center on Budget and Policy Priorities estimating that it would essentially “end most of government except Social Security, Health Care and Defense by 2050.”  President Obama proposes much more modest budget reductions and in some cases, increased “investment” in programs that would get the axe under Ryan’s plan.

And, of course, Romney and Ryan both propose to repeal the ACA, lock-stock-and-barrel, while Obama would continue to implement it.

So yes, this is a big election, with big choices on taxes, Medicare, Medicaid, coverage for the uninsured, and the role of government in funding just about everything.  But the dirty little secret that neither party wants to talk about is that Republicans and Democrats alike have embraced the idea of giving people vouchers to buy health insurance coverage, even though each disparages the other for being so “radical” as to even suggest it!

Today’s questions: What do you think about Republicans and Democrats alike embracing health care vouchers on their own terms, while attacking the other side for proposing them?

Tuesday, August 7, 2012

Does health insurance ensure access?

A staple of conservative critiques of universal coverage is that having health insurance doesn’t equal access. The corollary is that the uninsured already have access to care—from doctors and hospitals willing to take care of them on a charitable basis and from "safety-net" institutions.

This argument isn’t new, having been made years before the Affordable Care Act became law. In 2007, the Council for Affordable Health Insurance opined that "Universal Coverage Doesn’t Mean Timely Access":

"One of the false assumptions behind the push for universal coverage is that everyone will have access to care. While that may occur initially, within a short period of time the waiting lines begin to grow and access and quality begin to decline as the government limits funding for health care. Moreover, the uninsured do have access to care. . . some of it provided free or at discounted rates in public clinics. Having insurance coverage would be better, but the uninsured can and do get care."

Writing for the libertarian Cato Institute, Michael Tanner similarly argues that "health insurance does not mean universal access to health care. In practice, many countries promise universal coverage but ration care or have long waiting lists for treatment."

Dr. Marc Siegel, a physician, takes the argument even further, blogging in the National Review that he objects not only to the government mandating health insurance for all, but to the very idea of health insurance:

"The individual mandate may be the glue that holds Obamacare together by shoehorning in young healthy people who don’t need health insurance to pay for the sick and elderly who do, but an even greater problem than the mandate lies in the unwieldy insurance itself... Obamacare will make things much worse by increasing the number of people who are insured, expanding the procedures and other items (e.g. contraception) that are covered, and enlarging the government’s involvement in running it all."

(I find it ironic that many conservatives who object to ObamaCare because it will result in more people getting health insurance also advocate for converting Medicare to a defined contribution program where the government will give you—you guessed it—a voucher to buy private health insurance!)

But let’s get back to the main argument: that the health insurance doesn’t equal access to care, and that the uninsured can get care anyway.

It is true that health insurance by itself doesn’t ensure access—you need enough doctors to take care of patients, for one thing—but the evidence also is clear that being without health insurance consistently is associated with poorer access and poorer outcomes.

Here is what the Institute of Medicine found in its groundbreaking 2009 report, "America’s Uninsured Crisis: Consequences for Health and Health Care":

"A robust body of well-designed, high-quality research provides compelling findings about the harms of being uninsured and the benefits of gaining health insurance for both children and adults. Despite the availability of some safety net services, there is a chasm between the health care needs of people without health insurance and access to effective health care services. This gap results in needless illness, suffering, and even death."

What about those long waits for care in countries that have universal coverage? Well, yes, there are longer waits for elective procedures in some of them, but the United States doesn’t compare very favorably itself when measured on elements like access to primary care physicians and forgoing care because of cost.

In 2011, the Commonwealth Fund published a report and chart pack comparing U.S. health care to eight other countries (all of which have some form of universal coverage), and found that the U.S. was second worst in waiting time to get an appointment when sick, third to last in getting care after hours without going to an emergency room, and had the highest percentage of people who reported that because of cost, they did not get medical care, did not fill a prescription, or skipped medical test, treatment, or follow-up.

In 2008, I co-wrote an ACP position paper with my colleague Jack Ginsburg that compared U.S. health care to other countries’ and drew lessons from them.

We found that countries that ensure coverage through single payer systems may be "more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access." But we also found that they "may result in shortages of services and delays in obtaining elective procedures and limit individuals' freedom to make their own health care choices." Canada and Great Britain are examples of single payer systems.

We also found that "pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs." The French, Swiss and German systems are examples of pluralistic models that still manage to ensure universal coverage. (The United States, of course, is a pluralistic system that does not assure universal coverage, although the ACA is trying to get us closer.)

Finally, we concluded that "health care in the United States has many positive features and in many respects is superb compared with health care anywhere else in the world. Those with adequate health insurance coverage or sufficient financial means have access to the latest technology and the best care. However . . . the U.S. health care system is inefficient and inconsistent: health care quality and access vary widely both geographically among populations, some services are overutilized, and costs are far in excess of those in other countries. Moreover, the United States ranks lower than other industrialized countries on many of the most important measures of health."

In other words, an evidence-based assessment of universal coverage and the importance of health insurance coverage would find that:
-- Having coverage doesn’t by itself ensure access, but lack of health insurance by itself is assuredly associated with poorer outcomes and even more deaths;
-- Relying on a charity and safety-net providers is not enough to ensure access and quality in the absence of good health insurance; and
-- Because there are not unlimited resources, people sometimes will sometimes have to wait for care, and that this is true in every country. (In the U.S., longer waits for appointments, and delayed and forgone care, are mainly because of cost barriers associated with not having health insurance and not having enough primary care doctors; in other countries, longer waits for some elective procedures are mainly because of limits on capacity, global budgets and price controls.)

Clearly, people will continue to disagree on whether the ACA goes about the problem of getting people covered the right way, but conservatives should rethink their insistence that health coverage doesn’t really matter that much when it comes to ensuring access and quality (the evidence says it does).

But liberals should also keep in mind that giving everyone access to health insurance by itself also doesn’t guarantee access—we also need to address problems like the growing shortage of physicians, and acknowledge that administrative hassles imposed by insurance companies and government alike may be one of the factors that are keeping doctors away.

Today’s question: Do you think having health insurance coverage is needed to ensure access?

Friday, August 3, 2012

The “Undeserving”

“I am deeply disturbed by the unmistakable fact that I am not taking as good care of my patients as I did before. The appealing slogan that medical services should be ‘free to all’ sounds good. But when such a scheme is adopted, as Britain has done, these consequences can’t be escaped: a small part of the people who are malingerers, or who exaggerate their aches, or who are hypochondriacs and imagine they are ill continually clog our offices, take up our precious time, and constantly ask for unneeded care. They get in the way of those who really need care.”

The above quote, attributed to an unnamed a Scottish physician, is from a January 1950 Readers’ Digest article by then-University of Pennsylvania President Harold E. Stassen, decrying Great Britain’s National Health Service.

Stassen, you may recall, ran unsuccessfully for the Republican nomination for President of the United States 12 times between 1944 and 2000.  He concluded—based on interviews with British physicians and his own “intensive study”—that Britain’s newly minted National Health Services would lead to “More medical care at lower quality for more people at higher cost. ” 

Funny how things turned out: Just last week, Great Britain celebrated the same National Health Service at its Olympics opening day ceremony! Apparently, contemporary British don’t agree that their system turned out as Stassen had predicted.

An ACP member gave me a copy of the Stassen article during my recent visit to his state. He observed that the rhetoric against “socialized medicine” really hasn’t changed much in six decades. There is still a view that universal coverage will open the doors to the malingers and hypochondriacs, demanding care they don’t need and taking it away from the rest of us, and the related view that we have no obligation to pay for the health care of people who make poor choices.

Remember when last spring, a Tea Party audience at a GOP presidential primary debate cheered the suggestion that a (hypothetical) uninsured 30-year-old working man in coma should be allowed to die, because he had made the bad choice of not buying health insurance?

Now, I don’t think most critics of the ACA want the uninsured to go away and die.

But I do think that there is underlying tone to much of the criticism of the Affordable Care Act, which is that it is your own fault if you get sick and end up needing health care, especially if you didn’t bother to buy insurance. If you are overweight and out of shape, it’s you own fault—the rest of us have no obligation to pay for your poor choices. 

But the need for health care is not a choice.

Even the running-obsessed, non-smoking, non-drinking, slim and trim will get sick, if not right away, someday, and being a fitness guru is no guarantee of good health and longevity.

People do sometimes contribute to their own poor health by bad lifestyle choices, but there are many other factors at work, including bad genes, bad luck, bad parents, unhealthy communities, and poverty. (Most of the uninsured are poor.) And who are we to judge why someone is sick?

And sure, “free care” will lead to some people demanding services that they don’t need, as the Scottish physician complained about six decades ago, but is that a reason to exclude tens of millions of people from having access to affordable health insurance coverage?

Health insurance in my mind is not something to be earned, like a late model car or better house, the brass ring for hard work and ambition.

Sick people are sick people, no matter the reason and the choices they made, and they need our compassion and they need care. 

We are all in this together, we all need health care at some point, we all are deserving of compassionate and affordable care, no matter what choices we made, the genes we were born with, or how much money we make. 

Dr. Atul Gawande may have put it best, when he recently wrote “We are all born frail and mortal—and, in the course of our lives, we all need health care. Americans are on our way to recognizing this.”

I hope so.

Today’s questions: do you think some people are more or less deserving than others of having access to health insurance and compassionate and affordable care?