That’s a controversial question that emergency physician Edwin Leap asks in a recent column.
What’s missing in the current health reform proposals is language enforcing one’s sense of personal responsibility. So, as Dr. Leap writes, “there are people who really don’t deserve health care reform . . .The ‘elephant in the room’ is that some patients (rich and poor alike) do nothing to care for themselves, take no responsibility for their well-being, are never accountable for their actions and will happily bleed any system dry, public or private.”
We do need to find a way to cover everyone with affordable health insurance. Your job status shouldn’t be a primary determinant of whether you pay exorbitant amounts for medical care. But Dr. Leap says a dose of personal responsibility is in order as well, and “we have to be willing to address the morality of giving more of our tax dollars, with no personal expectations, to those who already cost us so very much.”
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I have been a family doc for 20 years. Two points: First, Dr. Leap needs to consider getting out of the ER. ER medicine is hard and burns out docs. Seeing people at their worst and never at their best is hard on a guy. We see this with our local ER docs all the time. Second:: Pt’s abusing their health has been going on for literally for as long as their has been patients. It should be considered within the spectrum of normal human behavior. Get used to it. There is no cure for normal.
There not their. Only one for in the sentence. Sorry, I need more coffee
Unfortunately, despite all the congressional and media rhetoric, they are unable to see many different elephants sitting in the room – patient demands for over-testing, paperwork and other dis-incentives to primary care and the PCP shortage, CYA medicine and yes, lack of patient participation. The dog and pony show seems only to be providing coverage, not cutting costs, and certainly not endorsing a system that enhances personal responsibility. Hence tax increases.
Wouldn’t it be great if we could reimburse patients in some way for lower A1C’s, weight loss, not inappropriately utilizing ER’s or not spending on unnecessary tests? We need more carrots.
This sounds a whole lot like Regan’s position on welfare. Before everyone get’s up in arms again about people who “don’t deserve” our tax money, let’s see some hard numbers on which demographics cost us how much.
For example, should people who are classified as overweight qualify for national healthcare? Should smokers? Should diabetics who became that way due to their excessive sugar intake? What about people who choose not to terminate a pregnancy knowing they will have a mentally retarded child?
I think you will find that the line can be drawn in many places and it’s a much more complex situation than a cut and dry in and out group.
Rick,
Let’s just scrap the government involvement in health care (and the massive public outlay of money) and then we won’t need to figure out such complexities. Let’s just say that need should not be a moral or legal claim on another individual. Let’s just say that people have a right to live their own lives and shouldn’t be forced, at the point of a gun ultimately, to pay for the health care of others. Let’s just say that those who are in unfortunate positions must rely on the good will and voluntary help provided by others.
“We do need to find a way to cover everyone with affordable health insurance.”
No, we don’t. Because there is no way to give everyone what they consider “affordable” health insurance. And even if we could find all this insurance at this magical number even then some people would decide to spend their money elsewhere.
Kevin has often said healthcare is not a right, but how far of a leap is it from “everyone needs affordable health insurance” to healthcare being a right? I would say not very.
David,
Something must be done about the skyrocketing cost of healthcare. The issue is that without help, like with any negative feedback cycle, a poorer working class leads to a less healthy working class which then again leads to a poorer working class. Incidentally, more poverty and desperation means higher crime rates.
Another issue with leaving things as they are is that currently when someone cannot afford healthcare they just go to the emergency room and don’t pay. Doctors have an oath they they must uphold and so will not withhold treatment. This means effectively that we are already paying for universal healthcare but without cheap preventative medicine and very costly emergency room visits.
Medical insurance is more problematic than most other types of insurance due to the relatively high predictability of individual future costs, and the fact that many expenses are somewhat discretionary in scheduling (i.e. people without insurance wait until they can get insurance before having something done — sort of like being able to not have car insurance until the day before you crash your car).
Because if this, adverse selection can easily occur; the insurance companies’ natural reaction is to avoid covering those with pre-existing conditions, and to try to drop those who develop expensive conditions. Taken to the extreme, the market for insurance eventually gets destroyed, except for perhaps the portion related to accidental injuries that do not cause long term problems.
Any type of medical insurance reform, whether market-based or government-based, needs to handle the problem described above. Of course, each type of reform has its own issues to deal with, such as the topic of incentives for people to avoid unhealthy habits.
Also, patient demands for over-medication, as well as doctors either going along with the over-testing and over-medication, or encouraging it.
A small example of over-medication is the routine use of opiod narcotics for oral surgery. But, beyond the cost of producing more narcotics than should be necessary, that leads to additional costs: patients’ delaying returning to work due to being under the influence of narcotics (or worse, driving or doing work that is dangerous when under the influence of narcotics); addiction and its attendant costs; extra narcotics from the prescriptions making their way underground to abusers and addicts; patients dulling the pain too quickly and not being gentle enough with the surgery site and causing post-surgery complications.
Rick,
I’m not sure exactly what people mean when they say “something must be done” about the cost of health care. It sort of sounds like a veiled threat: something must be done, or else…
In any case, if you are concerned about the cost of health care, then you should be concerned about what drives that cost, to wit, a high inflow of government money since the mid 1960’s. Medicare also (used to) have a policy of no questions asked when it came to paying for health care – so it was utilized greatly. Imagine if you were in the car sales business and someone walked in and said, price no object, just give me the best. Well, isn’t a Jaguar one of the best? Why given them a Fiat? Every market behaves this way. Indeed, look at the effect of the Cars for Clunkers program – did it immediately spur car sales – you bet – valuable but free (or discounted to the consumer) things get utilized very quickly!
As to your second point, I believe there are many laws (EMTALA and others) which tie the hands of emergency rooms. Hospitals in general are quasi-governmental entities which rely for their continued existence on Medicare, Medicare, government regulatory agencies, community perception of ‘need’, etc.. There are some newer emergency rooms which are private and which can turn patients away if true emergency is not identified. Much of the costs of emergency rooms actually has to do with providing routine care. And, by the way, all of us are not paying for this – for a large portion of it, the hospital ends up simply losing the money.
Anonymous,
I don’t think I’m sophisticated enough to address all of your points – but I think you must realize that we do not have much of a free-market in the insurance industry. You really don’t know what solutions the insurance industry could come up with for these problems because that industry is massively regulated, mostly by state governments. In most cases they are not allowed to offer a cheap, no frills, catastrophic type of insurance because the states demand that they cover mammograms, medications, mental healtch, etc.. Witness now the Obama suggestion that pre-existing conditions not be used as a measure of risk! Talk about not understanding the insurance business!
I think if insurance companies were able to change their charges according to an individuals risk – then you would establish a more sensible market. Right now health insurance companies are not allowed to do that! That means a healthy individual will pay the same premium as someone who is obese, has diabetes, or even has HIV. You must admit that this makes no sense and results in increased costs for everyone. Indeed, the healthy living incentives you desired would be built into the cost structure: people who controlled their diabetes, lost weight, avoided unsafe sex would probably be offered cheaper insurance.
Suppose a healthy person with insurance gets unlucky and his/her doctor says “You have cancer. We can schedule surgery next week, but you’ll also need chemotherapy for the next year.” The person’s insurance company finds out the next day and raises the premium to the cost of the surgery and chemotherapy. Which would defeat the purpose of a healthy person buying the insurance in the first place. How would you handle that situation?
Anonymous, with respect to your concern that “The person’s insurance company finds out the next day and raises the premium to the cost of the surgery and chemotherapy”
I would say there there are protections against such a thing. What you are speaking of would essentially be no insurance at all – as it violates the very nature of insurance. As a consumer, you are allowed to ‘build in’ protections against this sort of thing, by means of the contract you sign. Indeed, as markets develop, they compete both on price and quality (honestly and being known for sensible contracts being part of that measure of quality). As competition heated up, companies known for either violating contracts, or having stupidly written contracts, would be outed and people would perceive them to be the shams that they are. In addition, consumer groups (AAA for automobiles, Consumer Reports for household items, etc.) would expose these companies and, essentially, ruin their business. They would probably also be taken to court. Yes, a few people could get screwed early on (as with any outright scam) but you cannot completely eliminate crime from the world with extra rules.
As a result of our current regulatory environment, you just can’t imagine a customer-friendly health insurance company. I don’t blame you – but if you imagine health insurance companies having to compete in a market similar to that of cell phone companies or computers – you would see that competition really brings the best to a position of success.
It seems that risk stratification would defeat the point of insurance– i.e. spreading of risk. It would make insurance for sick insured individuals high, unaffordable, and then we are stuck with the same problem– the ED as the place for medical care for the poor and uninsured. So while it does “not make sense” that a healthy young person pay for an obese diabetic, an obese diabetic will never be able to pay for his/her premium and end up sicker in the ED. with higher costs in the end. I don’t agree with David– “that people have a right to live their own lives and shouldn’t be forced, at the point of a gun ultimately, to pay for the health care of others.” It is a fact that we already are, by subsidizing inappropriate expensive ED care via higher premiums for uninsured. Until we get rid of the law that forces ED’s to essentially treat anyone that walks in the door, health care will need to be a social project.
“… an obese diabetic will never be able to pay for his/her premium .”
I agree that the regulations covering the ED make the following impossible; however, should this person be allowed to get essentially unlimited care without properly reimbursing people for it? Is he or she “entitled” to that, or is this a person who will have to go without? I propose the latter.
Here is the thing: you can talk about personal responsibility all you want but the irresponsible will continue to come into the emergency room with their problems, and be admitted to the hospital, whether you like it or not. A lot of those people have no insurance and the hospital eats the bill. To talk about whether some people deserve health care reform is a moot point. The personally irresponsible will get health care and in the end we all pay for it.
Cell phone companies? Seems that cell phone companies in the US are among the more complained about companies around with respect to business practices and customer service; “best” here usually means “least worst”. You probably do not want to use that as an example for competition providing a good customer experience (especially since there are only four companies with their own networks in the US, although there are some additional virtual ones reselling service from those four). In some areas, the choice of cell phone companies is even more limited by coverage limitations.
Other types of insurance, for which there is more competition than medical insurance or cell phone service, are also not well regarded for business practices and customer service for the most part.
Why would removing the current regulations (including those which attempt to prevent insurance companies from dropping customers who get sick) necessarily cause medical insurance companies to be much more customer-friendly? The incentive to drop a customer who is diagnosed with a condition that will require tens or hundreds of thousands of dollars of treatment in the near future is likely an incentive more powerful than customer service ratings.
As an informed patient, I see physician’s frustration with ‘irresponsible patients’ as largely misplaced.
It is increasingly difficult to live a healthy life in a society where government-supported corporations overtly and subvertly promote unhealthy consumption. I don’t fall for prescription ads on television, but many people do. I know the majority of products in the supermarket are downright toxic and on the weekends I get in the car with a friend and drive 40 miles to shop at a market where healthy food is available. Most people don’t understand the issues in our food production system and don’t have the means to drive great distances to get basic foodstuffs. They see a food label that says “organic” or “high in vitamin D” and trust that they’re making a healthy choice.
I walk less and generally spend less time outside because my community and the surrounding area in central Massachusetts has been paved over with Walmarts, CVS, Walgreens, etc.
Lastly, my first point of care is the emergency room for even small things like a twisted ankle or poison ivy run wild. I know this isn’t a good thing, but it’s the only option available to me.
Devil’s advocate- I don’t think the choice for a diabetic/obese patient is between unlimited medical care without re-imbursement and letting them “go without”, although I am not sure what you mean by letting them without– is it medical care, unlimted medical care, insurance? If we let them go without any medical care or insurance, we are not only going to have a large uproar from society, but I predict real upheaval. In my experience, most who advocate your position do not understand that being healthy and unhealthy is not always someone’s choice, and that health can be taken away by circumstance beyond their control, and that insurance, understood as a way to minimize the risk, can work. I don’t think insurance means unlimited medical care, and yes, there will need to be rationing as the the problem we have in our country is that the costs are rising out of control. I also think that there needs to be some financial carrots for patients to increase compliance and healthy habits.
“For example, should people who are classified as overweight qualify for national healthcare? Should smokers? Should diabetics who became that way due to their excessive sugar intake? What about people who choose not to terminate a pregnancy knowing they will have a mentally retarded child?”
Wow, one of these things is not like the other. God forbid we don’t kill all of the mentally retarded to appease Rick Minerich.
Chris,
Please don’t claim to know my position on this matter. I included that intentionally inflammatory rhetorical question to make a specific point and I’m sorry if it was lost on you.
As they all end up costing us money and health care resources, the distinction between the things I listed is large only if you have a moral predisposition to see it that way. In fact, the idea that we should let our poorer citizens suffer with easily treatable or preventable diseases is equally sadistic as the idea of economically (or otherwise) enforced abortion of children who will be known to have terrible diseases. Personally, I’m for spending as much as necessary to see all citizens get basic health care and regular checkups as well as taking care of those who cannot care for themselves.
Your local supermarket’s rim (where stuff like fruits and vegetables are) does not have anything healthy in it?
Anonymous wrote “Cell phone companies? ….You probably do not want to use that as an example for competition providing a good customer experience…”
Actually they are a fine example. I love my cell phone, as do most people that I deal with. The complaints I have heard mainly have to do with coverage in various areas – but for most it is not a deal breaker. Cell phone companies, for the most part, try and succeed in providing a find product.
You also wrote “The incentive to drop a customer who is diagnosed with a condition that will require tens or hundreds of thousands of dollars of treatment in the near future is likely an incentive more powerful than customer service ratings.”
This is why good markets are powerful. It’s not just good “customer service ratings” it is the loss of market share. This is what most healthy (not health) markets are trying to do. If they fail enough, they will go out of business.
But regulation can significantly stifle this. When you are not free to offer innovative products, set your own prices, write your own contracts, you end up offering limited fare. In addition, with tax law often resulting in companies (not individuals) the buyers of insurance, you also limit choice.
It keeps getting repeated that “we all pay for it anyway”, but this is not true. The hospital pays for indigent care that it provides (sometimes, the city government will provide reimbursement for such care). That’s not ‘all of us’, that isn’t even 5% of us.
To the degree that there is some truth to this, then let’s change it:
(1) Slowly phase out Medicaid
(2) Slowly phase out Medicare
(3) Eliminate EMTALA and other laws which force hospitals to treat everyone (they can still treat people as they wish, but they wouldn’t be forced to do so)
(4) Reduce pain and suffering awards in courts so that medical malpractice isn’t so expensive.
Every individual should be free to live his/her own life without another’s need being a claim on his/her life and soul. If you want to help people who are less fortunate than yourself, then do so, but please don’t think you are helping society by giving the government the power to forcibly take money from one group of people and give it to another. The welfare state mentality (in health care or otherwise) ends up entrenching misery. The power seekers who lay claim to that money will always want more and the cycle will continue.
People should be encouraged, far more than is currently the case, to think and act on their own initiative and for their own benefit. This means being responsible for themselves. I believe that even if your circumstance was not of your own making, that it is psychologically healthiest to simply accept it and to make the best of it and to strive to improve your circumstances. Indeed, happiness is actually a product of achievement, not necessarily of how wealthy you end up.
Medical insurance companies are fine losing/dropping customers when they get sick. The model of being quite willing to collect premiums when people are healthy and dropping them when they become sick seems to be what they intend to do. Do you honestly believe that they will be any different in a completely individual market environment?
And it is not like insurance companies in other insurance markets (e.g. car and homeowner / renter, which are generally bought on an individual basis and in far more competitive markets and where future losses and the timing of such losses are much less individually predictable than with medical insurance) are that well regarded by customers. Indeed, they are heavily griped about for not paying claims to the expectation of customers, etc..
Recent surveys of cell phone users indicate that they are far from ideal in customer satisfaction.
Reading David’s many comments suddenly makes me very aware that the libertarian argument against health care is very much like the libertarian argument against marriage: It’s all well and good if you’re a healthy young male with no plans to have a child, grow old, or lose your income stream. The vast majority of us will grow old regardless of our best intentions to remain otherwise, and with old age many of us will lose our income. The child, of course, remains optional, but often desirable…even to libertarians.
Kim,
Ha! I’m not actually a libertarian, but it is interesting think that there would be an argument against marriage (I, personally, have a wife and child). Maybe you can explicate further. Your other comments also don’t make sense to me, to wit:
(1) I favor portable, high quality health insurance for everyone (and I think a market system is the best way to accomplish this). I have health insurance myself (because I take responsiblity for myself). If I thought I would always be healthy, why would I do this?
(2) I plan for my entire life – knowing I could lose my life (life insurance), become disabled (disability insurance), or become unhealthy (health insurance). I also know I will become old – and, unlike many others, realize I cannot rely on a ponzi scheme (Social Security) to keep me afloat. That is why I invest, save, and have a 401K.
(3) I plan with a range of 70-100 years of possible life. I intend to maximize my enjoyment over the coarse of this time, experiencing love, joy, family, the pride of building a business, adventure, travel, learning new ideas and gaining exposure to interesting cultures, etc.. I think everyone should do the same, to the best off their ability and means.
Why not pass reform that emphasizes more individual responsibilty. The American Academy of Actuaries recently published their findings related to health savings account-like plans (aka Consumer Driven Health plans or CDHs). This 10 yr experiment, which included about 8 million people has shown 12-21% overall savings c/w traditional plans, has not sacrificed access to preventative care and has led to greater compliance with evidence-based medicine. And it puts rationing in the hands of the people who are most likely to make the best decisions, the patients themselves.
“Lastly, my first point of care is the emergency room for even small things like a twisted ankle or poison ivy run wild. I know this isn’t a good thing, but it’s the only option available to me.”- Informed Patient
This last statement is a perfect example of lack of responsibility. The ER is not the only option, you could actually go see a primary care doctor and PAY him or her!
I would bet you pay a mechanic when your car breaks down, a lawyer when you need one, and a plumber when your toilet leaks.
Where did this attitude come from that healthcare should be free?
I love it!
Finally a physician steps up and speaks out.
Too many people are fat, addicted, lazy and apathetic or worse, who COULD do something about it and don’t – and WE THE PEOPLE, the taxpayers, pay and suffer because of THEM.
Additionally, too many doctors FAIL to tell their obese and non-compliant patients to lose the lard, seek bariatric Sx options or find out why the patient is non-compliant, etc. There are reasons. If more doctors spent more time EDUCATING their patients, instructing them to keep dietary or health diary’s and to write down questions BEFORE they come in for an appt, less time would be wasted and more focused care could be provided. Listening and makling sure the patient listens and understands (have them repeat back to you your instructions) would be a first step.
As a DES daughter, I have battled Clear Cell Adenocarcinoma IIIa and CCA IIb 2x (cervial/vaginal/bladder; ovarian to omentum) cancer and as a result of the Tamoxifen therapy post the 3rd set of IV chemotherapy I was Rx’d for 5 yrs, have had cataracts at age 41, and now at age 46 (starting since 1998) have stage IIb melanoma and multiple stage proliferating SCCs, et al.
I am 5′7″, 106 lbs, can bench press my own weight and eat, live and exercise better than most anyone I know. My TOTAL cholesterol is 159 (increased from 119 since living in Spain for a yr due to healthy eating of olive oil); w/my HDL at 106, LDL 43 and tryglicerides 43.
I take VERY good care of my health, yet my cancer was caused by the DES in vitro – not my fault. However, I still manage to be in better health than most – depsite the new cancers.
I have been paying for health insurance since my 18th birthday, along with military medicine my fathers earned as war veterans and Commanding Officers, as a Navy brat and for the last 5 yrs as a Navy and USN RET Officer’s wife. (We pay for CIGNA insurance here in Spain, utilitizing the services of SOS Int’l – which both, by the way, are SUPERB.)
So, yes, while an extreme and over-generlized statement was made by Dr. Leap – at least someone is speaking about the white elephant in the middle of the room and getting the dialogue going.
Take care America!
PS:
1) It has been determined the melanoma and SCCs were caused predominantly BY photosensitivity caused from chemotherapy drugs used to fight the previous cancers, (which were caused by a drug taken in vitro by my mother to prevent miscarriage, and we now know it causes it.) No, not MY fault, yet, I manage to battle and overcome it all and remain healthy-er than most. What about the reat of Americans?
Here’s a way to start:
– Let’s help educate kids in school from 1st grade on about proper diet and nutrition, healthcare, prevention, along with financial responsibility, et al.
2) I do not want to live to be 100, not this way. 70-75 Max would be fine. My advance directives are VERY clear there will be no tube feeding, no being kept alive as a vegitable on machines, no extra care unless it is a sure thing I can live as I am today – strong, healthy, ambulatory on my own two feet, etc…..I have lived a wonderful, etremely full life, traveled all over the world, had a great career, given time and love in vounteerism at hospitals and charities since 8th grade (age 12) and manage a full, busy life as a volunteer Director of Hospitality for 250+ international women, all the while enduring total face & body photo-dynamic therapy, caustic, burning 35% TCA peels, oral chemotherapy, etc.
3) Based on all the above, on Sept 1, when I see my Dr at MD Anderson Int’l Cancer Center here in Madrid to start “Acitretin” chemoprevention therapy (along with more MAL PDT, etc), I have MANY questions to ask about the MANY risks associated with this drug therapy.
– One of them is: “If this was YOUR wife, would you want her to endure all this? What are the alternatives? Dosage alt’s, and so forth?” Thanks to the internet and my access to medical journals and clinical trial results, I have a succinct, detailed list of educated questions, and have already sent them via email to him that we will review before I MAKE THE DECISION re what is best for ME.
4) Let’s end this Employer-based healthcare that started post WWII – that in itself will solve many portability and other problems. Many people do not do paid work and provide valuable contributions to society as mothers, wives, husbands, students, retirees, and more.
5) In CALIF, the state has home-owner’s insurance policy coverage provided via insurance companies that home-owners pay for at a normal, reasonable cost when they have (e.g:)the old style shake roofs in So Cal, and cannot get insured by their regular carrier. Something like that may be a solution for those with high risk health issues…..
Worth a discussion.
PPS: Pardon my typos – one eye Sx for cataract to go!
Doctors need to unionize!!!!!!!!!!!!!
Seems to me this question/argument is moot. The reality is the bottom line, and the bottom line is this!
America ranks 37 in the world’s health ranking system.
/a<
America ranks 24th for life expectancy
<a href="http://www.photius.com/rankings/healthy_life_table2.html"
America ranks 72 in overall health system performance.
<a href="http://www.photius.com/rankings/world_health_performance_ranks.html"
American is number 2 in the world for health care expenditures.
<a href="http://www.photius.com/rankings/total_health_expenditure_as_pecent_of_gdp_2000_to_2005.html"
Wow! Seems to me that we absolutely FAIL at caring for our own people. The level of ignorance in this country is not only shameful, but frightening! Here’s an idea, before playing with the “bourgeois concept of WHO should be eligible for health care, why don’t we do something inspired and semi-intelligent, like maybe I don’t know.., make the health care system actually function for EVERYONE, first? Suzette M is impressed that doctors are now actually stepping up and speaking out. I say if this is an example of the best conversation they can come up with under the circumstances, PLEASE, I beg you, don’t step up! As for Suzette M herself? obviously she has access to healthcare. Brava! Unfortunately 45,000 other Americans with the same condition, be they fat, ugly, whatever, will just..,die.
But there’s always a silver lining in every dark cloud. (right?) Here’s something to make us feel better through all the ugliness, at least our health care ranks higher than Turkmenistan! Now we can throw that fact into our sophisticated conversations about death panels, 8 month waits for vital surgical procedures in the UK and those pesky patients who don’t deserve health care, over that next cup of joe at Starbucks! Here’s that link so you can forward it to all your friends too. <a href="http://www.foreignpolicy.com/articles/2009/07/22/the_list_the_world_s_worst_healthcare_reforms?page=0,2" Gosh, I feel better already!
Messed up some of the code for the links, just cut and paste to see the reports
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