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?


Harrison said...

Maybe I'll take a stab at this.
Bob, I think you are setting up a straw man position so you can argue from a place of moral superiority.

I too love to do this.

So we can consider this from a couple of different angles.

I don't think anyone wants to argue from the position that the sick don't deserve care.

But do doctors have to take care of the most complicated health care problems for the lowest remuneration?

The British system does a good job with this.
We could too, but it would need to be funded well enough and supported well enough with a care model that made it work.

I think your question should have been about how dishonest the debate in the US is about the horrors of socialized medicine and how that debate has been virtually untouched for so many decades.


Steve Lucas said...

The Tragedy of the Commons will always be with us as we can see from this post:

Dr. Wes looks at the numbers in his state and finds insurance may not equal coverage and that a group will now pay a tax or be forced into buying coverage.

There are things I like about the NHS. The VA saved my father from an unscrupulous doctor who, while wanting to “make sure,” subjected him to repeated urinary track scopes in his office. The VA did do the test once, in a hospital, with anesthesia, for liability reasons.

Going forward it is important to remember that the Democrats in Congress average 70+ years of age while the Republicans average around 40. This will change the debate as the old liberal guard pass and these younger politicians take over. Tending to be more pragmatic and conservative, with a larger world view, the debate will have a very different tone in the future.

Steve Lucas

Arvind said...

Bob, nobody is arguing that people don't need compassionate and affordable care. Those of us that oppose ACA simply say that ACA is not the answer - it will not achieve either affordable nor quality care, as those that support it expect to happen.

Whether you call it socialized medicine or some other name, people will utilize more care when they don't need to pay for it.

So, insurance must be used as it is described "insurance", not for 1st dollar pre-paid coverage plan that the ACA dictates.

And, when will we as a society start to realize that we all have to live (and die) by our decisions? As a parent, I make it a point to remind my kids of this truism every day.

Did the ACP ever come out openly and tell its members that its objective was to help convert American medicine into a form of the British NHS? Perhaps that would have been a more honest process....

ryanjo said...

I have to admit, I kind of envy Bob and his ACP-leadership brethren. They have such a pure idea of the potential of the ACA, up on the moral heights that they peer down on us doubters. To aspire to the glory of the British NHS, the dancing nurses and doctors on the Olympic stage! The same NHS that is going through its 4th (or 5th) radical reorganization (See: With a likely cost of £4 billion, the Health and Social Care Bill has all the hallmarks of an avoidable policy fiasco, Well, that certainly couldn't happen here. Perhaps with ACA in effect, I will learn to dance, even if it is at the end of Mr. Obama's puppet strings.

On a more serious note, I think it is important to heed the view of critics in any national health policy debate. Characterizing us as morally deficient, and equivalent to those who would let the uninsured die, is a convenient way to quiet nagging questions about the ACA. Why was it pushed through without a single vote from the other side of the aisle? Where is the real money to come from? (not the phony $500 billion from reducing waste). Why does our government place itself in a central position as far as quality of care and financial checks and balances -- with such a shameful track record with other national agendas? Why are the principal means of delivering care (small practice physicians) being tossed aside for untried consolidated structures such as ACOs? We are jumping into the abyss, led by the very idiots who have turned our republic into a quagmire.

When critics are silenced, ridiculed, or ignored, sometimes the results are good (Desegregation), and sometimes not (the rise of the Bolsheviks and National Socialism). But in either case, the transition is likely to be rocky. You need everyone on board for the push, not just the true believers. That's what makes me worried.

Unknown said...

The health care debate has never been about health care. Its been about health insurance.
We spend the most but are way down the list on infant mortality, chronic degenerative disease, etc. Until people take responsibility
for their own prevention of disease and e stop handing out pills like candy, the mess will continue and the US will continue its course to bankruptcy.
Diet, exercise, right relationships, rest and relaxation, good water and air, fun, and daily meditation need to be taught.