Apr 27, 2011

Healthcare Should NEVER Be Free

Is Healthcare A Right?

Yes, Healthcare
probably is a right, but it should never, ever be free

Now Dr. D is a Socialist (I’m not talking little ‘s’ Palin-calling-Obama-names socialist, but big ‘S’ from-each-according-to-means-to-each-according-to-needs Socialist) but he still believes medicine should never be free if we want to keep it.

So what’s a nice Socialist boy like Dr. D doing defending the financial exploitation of sick people?

Okay, now that I have your attention…

Rights and Responsibilities

If something is a Right then it must be someone’s Responsibility too.

We have the right to vote. This means someone is responsible to run a fair election and count the votes. We have the right to a fair trial. This means someone is responsible for maintaining an impartial court and providing a public defender. Make sense?

If Healthcare is a Right then someone is Responsible for funding and running an efficient healthcare system that cares for everybody... and that someone is Dr. D.

Dr. just paid about $60,000 to the US treasury and as a bleeding-heart he also did a lot of volunteering and giving to healthcare for the poor. (Dr. D puts his money where his Socialist mouth is!) Like most people with well-paying work, D contributes large percentage his resources toward the general welfare.

Dr. D is also the dude that gives away the free healthcare.

WTF, free healthcare in the USA?

Yep, if you are broke ER care is free by law.
News Flash to Republicans: Socialist Medicine has been here for decades! Doesn’t it just make you feel dirty?
If Healthcare is a right then Dr. D is the dude responsible, because over half my waking hours and dollars earned are spent providing that right. Actually, we are all responsible for it.
We're already providing free carewe’re just doing a piss-poor job of it:

Bad enough that Republicans are right to complain that our kids already owe China trillions of dollars we’ve wasted on healthcare.

Also bad enough that Democrats are right to point out that millions of uninsured are sick and dying without the care they need.
The current state of the healthcare system

So let’s think responsibly about this...

Human Nature Is a Bitch

We Socialists are big picture dreamers. We like to feel we do some good, without get bogged down in the details. Young D used to give a $10 to every homeless dude that asked. It felt good and kept me restricted to a diet of mostly ramen during school. Then I started working at homeless shelters and realized that the bills I gave usually ended up spent on crack. Giving a crackhead money isn’t responsible. Responsibility is a lot harder.

Are you comparing sick patients to crackheads? Yep!

We are all subject to the same rules of human nature. The problems of human nature affect everyone and always fuck up our brilliant plans. (This blog has spent considerable time dissecting how the foibles of human nature make doctors one of the most screwed up and difficult types of people you'll meet.)
Humans are naturally self-serving and take the path of least resistance.

We occasionally rise above our natures, but when we create a system we should expect people to generally act like typical human beings—and by ‘typical’ I mean jerks.

We guarantee the Right to vote and to justice, but because we recognize that human nature people lust for power we have to make a Responsible electoral and jury system that isn’t easy to cheat.

I’m in favor of giving free food to people that need it, but if I laid out a buffet of delicious food on the corner with a note that said, “Just take one plate, and only if you’re hungry.” It would likely all end in the trunk of the first person that drove by—even if that person already had a million in the bank.

Sorry, but human nature sucks! Why do we expect free medical care to be any different?

But people wouldn’t do that with medical care would they?

Dr. D sees it every single day: People call ambulances to bring them to the ER for runny noses and dry hands. People getting a free $1000 emergency room visit demand antibiotics for viral and then don’t fill what is prescribed. People come to the ER to get “checked out” just because there’s nothing good on TV.
Most people will treat anything that’s free like it’s worthless and waste it without even thinking. Just look what we did with this planet God freely gave us!

Free Stuff Has Consequences

Medical care actually isn’t free. It is really expensive. It takes a lot of resources and work to create even the simplest doctor’s visit. Somebody is responsible to pay the bills for free care, and even though Dr. D chipped in $60K this year, our kids are still in the hole for 14 trillion bucks.

A responsible system must be sustainable, and free-for-alls just aren’t sustainable.

The freeloaders also screw up system so it can't work for the people who actually need it. Dr. D gets to deal with a microcosm of this every time we don’t have space for real emergency patient because the ER is full with people who checked in because they were bored or lonely. It happens a lot.

Rationing Healthcare

Healthcare is a right. We owe it to our fellow human beings. We would be some sorry bastards if we just sat by and watched poor people die preventable deaths. We owe it to our kids to create a responsible and stable system to guarantee these rights. The only way I see that you could possibly have free medical care is if it is heavily rationed.

OMG, did Dr. D just say rationing? Get the pitchforks and torches! (BTW, I love how my Conservative friends get so worked up about rationing something they don’t want people to have at all.)

Human beings will frequently use their freedom to go all apeshit. We need to have someone responsible enough to prevent us from exercising our rights to the extent that we harm others.
We have the right to be free but we also have the police to arrest those who use their freedom wrongly.
But nobody wants a police state and nobody wants a free medical system that is constantly saying NO.
Totally free healthcare might not be as nice as you hoped.

What we really want is for people to restrain themselves. Some saintly folks may do this, but most of us will follow our baser natures to disastrous results.

Valuing Healthcare

Yeah Dr. D, but if human nature is really that shitty why doesn't everybody misuse their freedom and end up in handcuffs?

Sorry to bruise your college-educated ego, but it isn’t because you’re such a better person. You just have a whole lot of incentives to stop you before the handcuffs. Some are social incentives—you’d be ashamed to act out—but many are financial. Misbehaving will hurt you in the pocketbook.
Everyone has different values and motivations, but we all accept that money has some value. If we want universal access to medical care then it has to cost money.
It doesn’t have to cost much money. In fact healthcare is best if kept inexpensive. The “free market" cost of healthcare is a huge barrier to most people’s access. But there has to be some barrier. Drop the cost to $0 and you get a tidal wave of people wasting very costly care.

I guarantee that if every person who came to the ER had to pay $2 up front the number of frivolous visits would drop by 80%.

I’m not saying that no rationing will ever be a necessary, but if we insure healthcare has value to everyone rationing care will be the exception rather than the norm.

You want everyone to have healthcare? Never give it away for free!

Okay, Dr. D has managed to piss off both the Left and the Right!

The floor is now open to your comments. Just try and be civil with each other.

Next post Dr. D will studiously avoid politics and return to the regularly-scheduled programing on Doctor-Patient Relationships.


K said...

Having come from a country where healthcare is government based and is essentially free, I WHOLE heartedly agree with you and this post! I pray and hope and wish every day that this country N-E-V-E-R has free healthcare because it will be HORRIBLE healthcare. Nothing that's free in life is worth taking. I just wish people here understood that! (although theoretically in an ideal world, just like communism's concept sounds "great" to many people, free healthcare sounds great, too). In practice, Communism turned into Marxism, which turned into Leninism.

Catherine G said...

After working as a street medic for a number of years, I can attest to the misuse of the "free" care at an ED. Some patients would call an ambulance because they believed (mistakenly) that they would be seen faster. One patient called because he felt, "icky" (he was a newly diagnosed diabetic) and wasn't comfortable using his blood glucose meter. En route to the hospital, he noticed a column of smoke out the ambulance window and asked about it. The answer was, "That's a guy trapped in his burning car a few blocks over, he's waiting for the ambulance from the next station over to get to him."

I am currently teaching in public schools, and am seeing an unfortunate trend in my students that Dr. D pointed out. If something is free, people will take as much as they can get even if they don't need it; and once they have it, many aren't willing to share if others didn't get any.

I personally believe that if this country devalues quality healthcare by making it free, the results would include fewer highly capable people entering the medical profession, due to the decreased value of the service they provide.

Anyway, that's just my 2-cents.

emmy said...

I have been in the waiting room of an ER, nauseated and in pain because of the chemo I had hours earlier and thought "If everyone here had to go to a 24 hour walk in clinic that they had to pay $10 at to get permission to come here, I wonder who wouldn't have come?" It was a sad night.

Absentbabinski said...

British nurse-turned-would-be-medic here and the longer I exist in the healthcare space in the UK, the more I suspect rationing is the only sane route.

Healthcare is "free at the point of entry" in the UK, which doesn't mean that it is free as in beer. Taxes support it and anyone who earns (or buys liquor or cigarettes) contributes, there is nothing free about the NHS. But needs will always outstrip resources because that's just the way things work and cuts will have to be made from time to time and treatment options will be limited - by as a humane cost/benefit analysis as possible. Rationing of resources is something Brits are familiar with and (until very recently) we had bodies such as NICE to recommend treatments based on evidence and putting a cash value on quality assessed life years (about £30,000 a year, I think). You can argue with the relative merits of this.

The real, dirty secret when it comes to healthcare, especially government subsidised (or, as some call it, free) healthcare is that money would be better spent providing quality housing and education for the most disadvantaged quarters of society. I'm not trying to espouse hippy, liberal ideals - this is the stuff that really makes a difference, hell, is proven to make a difference. However, this would not provide results in a decade or two and in the meantime there are people piling up for treatment for preventable (and easily preventable, at that) diseases.

I appreciate that Dr D is talking American healthcare and I'm sure my understanding of it is limited by how little exposure I've had to it and my comments are of limited relevance, but I just wanted to throw in my ten cents regarding exactly how "free" free healthcare really is.

Anonymous said...

Hi Dr. D,

First of all I really appreciate that you volunteer your time and work with your patients to make healthcare accessible. As some one who appreciates the healthcare I get, it really bothers me that I'm still not garaunteed to at least have health insurance in this country. I spent 10,000 on medical last year. I'm not poor enough to qualify for any government programs, and I can't go to urgent care instead of the ER because I have too many major medical conditions. I bet a lot of poor people go to the ER because it is free....and think that if there was more free medical care in doctor's offices that maybe they wouldn't waste money like that.

I do agree that nothing should be entirely free....but paying 200-400 dollars to see a doctor that I need to see opposed to a co-pay that is manageable can make a huge difference. My current co-pay to see a specialist is $60 which is kind of insane if I see more than one a month (which has happened lately).

Oh, I'm also fine with rationing actually. I think we already have rationing in the US for healthcare, it's just that no one calls it that. One of the specialists I see is very very specialized, and they are always triaging because of it.


Daisy said...

I am an American living in the Middle East...the land of free Healthcare. Let me put it simply... I miss my American Healthcare! :( I simply hate it here! I take back any bad thin I ever said about the American Healthcare system....the healthcare insurance system, well, thats a whole other ball game.

Kelly said...

I took a course on taxation in law school, and we spent a lot of time discussing how employer-provided non-taxable medical insurance has led to the over-consumption of healthcare. If employers created a cap on the amount of money they would offer as healthcare benefits but allowed employees to choose to take the value as cash or medical insurance (or a mixture), and both were equally taxable, employees would do a much better job at choosing a healthcare plan that really matched their needs (there would be no incentive to choose an over-comprehensive plan since it would reduce the remaining amount they could take as cash). Younger, healthier employees would probably opt for a greater percentage of cash and a more minimal healthcare plan while older employees would probably opt for a more comprehensive plan. Ultimately, people would only consume what they actually need instead of going to the hospital just b/c they have health insurance and feel it's a use-it-or-lose-it situation. A lot of tax experts apparently believe that taxing healthcare benefits would have the largest immediate impact on reducing the large demand on our healthcare system, and would eventually change the way employers compensate employees.

You already went into the problem w/ our healthcare system on the supply side when you discussed how difficult it is to establish new medical schools and the long and expensive process for becoming an MD. Demand is artifically high, supply is artificially low, and politicians would rather just make really broad statements that don't really address any of these issues.

It seems like if we could address the beast that is employer-provided medical insurance and start working with the AMA to figure out how to expand our supply of healthcare professionals, we wouldn't even really need to ration the system. We didn't have rationing in the late 1940s, and somehow my working-class grandparents were able to afford to take my father to the doctor. That was before the popularity of employer-provided health insurance made it extremely expensive to see a doctor.

Unfortunately, I agree with you about the shittiness of most people. I think there would be a lot of public outrage if the government started taxing health benefits, and not just from conservatives who almost always oppose higher taxes. Public and private unions have been very successful in demanding great healthcare benefits for their workers. I can't imagine even those traditionally left-leaning groups not putting up a fight against the taxation of those benefits. Employers would need to change their compensation schemes in light of this to allow workers to adjust in light of a heavier tax scheme, but even so, I still imagine public outrage would be high (even if people don't value something very much, they still feel screwed over when that item is taken away from them or they have to bear the full cost associated with that item).

So to summarize: a right-leaning Thomas Sowell follower just made an argument in favor of more taxation in order to reduce the demand on our healthcare system that was created when the government started handing out non-taxable health care insurance like candy in order to appease workers during wage freezes! I feel like a traitor to want more taxation.....but at least I got my dig in at the government.

Barbara said...

There will always be people who work the system. You cannot punish those in need for the actions of some. We have laws against robbery and other crimes, but they do not stop it. We don't punish the victim. Crime is higher in poor areas.

This country tends to view everything in a vaccum, issue by issue. But it is all the same issue. Wages. Wages have declined at the same rate as union membership has declined based on cost of living. Companies used to offer healthcare to attract employees, now with jobs being scarce, they don't need to offer it now. Lower wages means that more people need public assistance and those making low wages pay lower or no taxes. And oil companies and GE and others pay no taxes. If you decrease revenue, then you decrease services that are needed, like health care, paved roads, and money to educate doctors, Medicare, garbage collection, police, etc. I love it when people complain the ice is not off the street fast enough......you want that, you gotta pay for it.

Low wages also mean that people keep seeking a better job, turn over is higher, and experience goes with those employees who find better wages. If they can't find better, then they have dissatisfaction with a job which can effect performance and health. If you make $8 an hour, you choose between food and medicine, electric or water, and you are more likely to smoke, drink, domestic abuse escalates, and you are likely to suffer depression and more ills. As long as CEOs get bonuses for poor performance, this will continue.

Premiums paid by some pay for the uninsured. Health insurance companies are for profit,not health. But if you close them all down, you add to the unemployement rolls. We created a monster when we started health care for profit.

Massachusetts has universal care. Hawaii has had it for like 40 years. Vermont is now voting on "socialized" medicine so employers are off the hook. Let's look at those and see what successes and problems they have and go from there.

The so called pro-lifers should be in favor of universal health care. Doctors, nurses, EMTs etc are the ultimate pro-life movement. They extend and improve life. They should be paid based on that value. Maybe doctors need a union. The old saying is true, if you have your health you have everything.

The Nerdy Nurse said...

rationing would be needed for some, but then again, perhaps those that need the rationing would be able to get the mental health they need in order to avoid the act of rationing.
That and the $2 admission fee to the ER, would surely stop that tidal wave of wasted medical care.

R. McCarter said...

The only things that are free or should be free are the inalienable God given rights that every person is born with. I have the right to work my ass off if I want to prosper I also have the right to sit on my ass and do nothing. I do not have the right nor does anyone else to sit on their ass do nothing and expect something. In order to get something for nothing someone has to take away that somthing from someone and give it to the someone that did nothing. This is socialism and this is why socialism will never work because it rewards the do nothings and punishes those that are achievers. As they used to say in the Soviet Union before its fall "I pretend to work and the government pretends to pay me." Whenever there is an attempt by government to equalize society that society inevitably fails due to the lack any incentive to achieve more than the next person because it will be taken away from the high achievers and given to the non-achievers. Those that work more or harder or smarter find no desire to do more if the hard work the extra hours the due diligences do not gain any rewards for the extra efforts. If I have two cars because I worked harder than my crack head neighbor and he needs transportation to get to his AA meeting and the government aqusitions my mercedes and gives it to him/her in order to make society more equatable well then I hope you have the intuitve sense to see what this means and where it leads. Incentive is absent and any attempt to raise ones standards is gone. Why do more work give more effort and recieve nothing for such. It is basic human nature to take the path of least resistence to stop at the point of diminishing returns. The simple fact is that people are basically selfish and want something for their efforts and many are so selfish as to take from others if possible without any effort. Another term for this kind of behavior is stealing. Now I am not saying that there are some people that have genuine needs that they themselves can not provide. Such as those misfortunate enough to have been disabled beyond the capability of providing for themselves but those that are capable do not have the right to take from me or you the inaliable right keep what we earn and distribute it to someone that will not work or work as hard or as much as I do or you do. A person is entitled to what they work for and nothing more period. Now to get the the reason I am even commenting on your blog et al the following. I have been a registered nurse for 17 years and I have started a blog about the government and the alarming fact that you and your families personal privacy is at risk. The new HIPAA 5010 law that passed this year sets legal standards for the confiscation and de-identification of yours and your families’ personal electronic health care records. There is now no legal reason for permission to be obtained from you in order for your personal health care records to be confiscated and distributed to clearinghouses for de-identification and used for research. Most health care providers do not know this and certainly most U.S. citizens are not aware of this. Follow my blog and learn how to take control and keep the government and other private agencies from accessing your private health information. Follow my blog at http://blogbur.blogspot.com

Alessandro Rosa said...

I think that the biggest problem is the mechanism with which the law chose to provide health care. Politicians in their infintesimal wisdom said, "Well we have lots of people who can't afford care and well they may actually be sick and that could make us sick so we need to get them care but we don't want to pay for it, but we already have lots of Emergency Rooms that are used to taking care of sick patients at a moments notice, so we will just make it a legal requirement that they treat these people..." instead of actually coming up with a workable solution which didn't cripple the system.

It would make much more sense to have these mandatory services provided in non-ED clinics by PA's and NP's, overseen by one attending, who could either treat on site or triage to the ED patients who do not have the means to afford a personal doctor. Doing this would provide a lower cost alternative to mandatory Emergency Room admittance, free up the Emergency Department to treat actual Acute Emergent conditions and still let people get the care that they deserve.

I also see your point about requiring some for of payment. I'd go even so far as making it some amount that would make people think, like $25, and have an unwritten policy that the patient can claim that they don't have the money, will still be seen but will be billed, then if the bill goes unpaid after some period of time, maybe 180 days, instead of sending the amount to collection, assign it to a dead file and write it off. I might also go a step further so that if someone calls an ambulance and a thorough work up shows that the illness wasn't life threatening or couldn't have been mistaken as life threatening (i.e. chest pains related to a panic attack which could just as easily have been a life threatening arrhythmia or MI) then the person is responsible for the cost of the ride.

a-jay said...

In Norway the publicly funded healthcare system works like this:
When visiting a doctor, you have to pay per consultation, but you don't pay the full cost of the consultation, only a small sum called the "own contribuion" (typically about 25-35$). The rest is paid for by the government/taxes.

When the sum of the "own contributions" you pay during a year exceeds a sum set by the government (currently about 330$) all additional consultations is free for the rest of the year. Next year you start from scratch filling up the quota again.

The advantages with this system is that it costs money to actively use the health system while ensuring that it is still affordable for chronics and others who actually need to visit the doctor often, and that it is relatively easy to administrate (compared to a system where chronics have to apply to have their fees covered).

Anonymous said...

I'm glad I live in Canada
When you are sick, none of this bull&$@! matters, you just want to get better, preferably without any unnecessary political or financial obstacles along the road to recovery.

Anonymous said...

OK, one restraint, indeed the only one that will work, on those who would abuse health care is if they paid a share of it each time. To put it differently, lets have "society" (that's we taxpayers) pay the same share... maybe 1/3 of health care and health care insurance for everybody. I suggest we do it with a high rate flat tax (33%?) and a high personal exemption to make the tax affordable to all. Not enough? Pay the poor the difference between their deductions and their income multiplied by the above rate. That means everybody gives up 1/3 of what they earn, either in taxes or reduced benefits. (I suggest the same for education, and savings but NOTHING more. 33% sounds high but kill off all business taxes while you're at it. Guess who pays business the money with which they pay their taxes now? You, their customer. Let me here from you: tbeebe6535@yahoo.com

Adam Martinez said...

I think It's simple philosophy those who think everyone should pay for health care at big amounts are narrow minded, those who do not are broad minded, greedy or not greedy, I wonder if a rich man who literally goes broke with zero dollars, and was against free health care, would like a surgery to save his life? Hmmmmmmmmmm, yeah that should answer your question narrow man

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