The recent health care discussion in the media has centered around the implementation of the Affordable Care Act, now no longer a lengthy, inert document but rather a living, breathing manifestation of what should be a collective, unambiguous vision for the delivery of care in the United States. It is, however, anything but comprehensive in scope, and the coverage has primarily focused on crashing websites, politics, calls for resignations, and apologies.
The attention to these unfortunate blunders is merited. However, I believe they should be no surprise and were, in fact, inevitable. This is because we, once again, have shifted our attention to tactics without first agreeing on a strategic direction — the clear, comprehensive vision that must drive any sincere attempt at improving the delivery of care in this country. We still haven’t answered the most important question before us. Is health care a business or a right?
I once thought the most ethical solution lay somewhere in the middle, between individual responsibility and collective compassion, but I now feel strongly we need to choose a singular direction. If we look at the current system as a whole, it quickly becomes clear that it is rife with contradiction and lacks any clear, consistently applied assertion of our society’s values, treating different entities, all ostensibly operating in the same space, differently.
It appears we only struggle with calling medicine a business in the doctor’s office, at the “point of sale,” so to speak, in the places where care is actually delivered by those that actually deliver it. The other players in health care, including insurance companies and biopharmaceutical companies, have no qualms about clearly stating their position — they are engaged in business for the sake of profit.
If medicine is a business, though, then let’s all just call it that, move forward boldly, unapologetically, and look patients in the eye and say, “If you can’t pay for this, you’re on your own. It’s your life; it’s your responsibility.” And no more employer-subsidized managed care at work either, only privately purchased catastrophic insurance coverage with patients reaching into their pockets for any other care they need.
There shouldn’t be any shame in that approach. In this country, we don’t demonize good landlords simply because they demand their tenants pay rent. And employers generally don’t subsidize your rent or mortgage. Similarly, we don’t castigate or imprison restaurant or grocery store owners that turn away the hungry and homeless, nor do we mandate the purchasing of “food insurance.”
Yet food and shelter are both basic human needs, even more critical to survival than health care. Why should health care be any different, then? Sure, health care costs are exorbitantly high, but, once the existing schism between payor and patient is eliminated, costs will decrease necessarily. In fact, the exorbitant costs are, in part, the direct result of our historical attempts at treating health care differently.
If we started relying on insurance to pay our grocery bills, a gallon of milk would soon cost two hundred dollars. All goods and services, no matter how critical to survival, must be paid for by the individuals consuming them. Economics teaches us that any other approach leads to derangements of price and renders the protection of supply and demand impotent. This is particularly true of the inelastic goods and services found throughout health care; introducing third parties to execute payment guarantees perpetual price increases and leads to further misallocation of scarce resources. So if health care is truly a business, it must be run that way.
Or, conversely, let’s make health care an inviolable right of every citizen and hold our government solely responsible for its delivery. That’s also a viable solution that, in theory, has the power to bring equity and universality to the delivery of medical care and is not without documented precedent in our country. After all, it’s difficult to fully engage in “life, liberty, and the pursuit of happiness” when you’re either dead or suffering in silence, unable to afford life-sustaining care or medications.
But if we follow that path, we need to approach it without reservation as well. The entire industry would need to understand that profit, other than to sustain ongoing operations and modest lifestyles, is no longer a justifiable motive unto itself. In many regions of the country, the control over physician reimbursement by what borders on insurance industry collusion is so pervasive, so complete, that there already exists little real variability in remuneration, anyway. In many ways, health care has already ceased being a true “market” in those areas.
We don’t live in an imaginary world, one with unlimited resources available to satisfy competing wants, where the laws of economics can be bent to satisfy inviolable rights. The two concepts are, and always have been, distinct and irreconcilable. That is why we don’t have any “freedom of speech marketplaces” or “freedom of religion exchanges” where one can trade these rights for profit or procure insurance to ensure access to them.
More importantly, a hybrid system obliterates the benefits of either solution. Currently, patients are not only vulnerable to the dangers of unchecked corporate excess but also the bureaucracy and ineptitude of government. We are forced to endure the flaws of both without reaping the full benefits of either. Yet we choose to simply muddle somewhere in the middle, apply “patches,” and undertake “fixes.” And we insist on treating health care delivery differently than equally critical products and services in other industries.
We just haven’t made a choice. And until we do so, until we set aside political correctness and the false beliefs that have driven policy for far too long, the news will continue to be dominated by crashing websites and political posturing. There is nothing wrong with calling health care a right, and there is absolutely nothing wrong with calling it a business, but, in the real world, it simply can’t be both. So which one should it be?
Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.