Health care reform discussion continues
Legislative process moves ahead
I believe that underlying [the health care reform] debate is our national schizophrenia over whether health care is a social good or an economic good. We often say the former, but the reality is the latter. We say health care is a 'right' not a 'privilege,' and we deplore that not everyone has access to health insurance.
"But we also believe that there should be competition in health care and that 'the market' should prevail. Because the real underlying value of American health care is "market-based competition," perverse financial incentives have developed."
— Blair L. Sadler, writing in The Hastings Center's Health Care Cost Monitor blog, on July 13, 2009. Sadler, JD, is a past president of the Rady Children's Hospital in San Diego; a senior fellow at the Institute for Healthcare Improvement in Boston; and a faculty member at the Rady School of Management at the University of California, San Diego. Sadler is a Hastings Center Fellow and board member.
According to Nancy Berlinger, PhD, MDiv, deputy director and research scholar at The Hastings Center in Garrison, NY, Sadler's commentary points to the classic dilemma, which Sadler also refers to, of "margin vs. mission — no margin, no mission."
She interprets his comments as alluding to the health/wealth gradient, which is the idea that the higher your wealth, the better your health. Also borne out in studies is the fact that the poorer one's health, the more likely that individual is to have lower income.
"People are in the hospital because they're sick. But the conditions that brought them to the hospital may have something to do with their income or their economic circumstances."
Perhaps someone decided to forego an important diagnostic test, and a disease was diagnosed at a much later date — or treatment or medication was too expensive, so a chronic disease became acute. These are all realities in today's health care system, Berlinger says.
"It hasn't been explained by any one factor," she says.
Berlinger says that countries that want their populations to have better health can either "work it on the income side and hope that if people's fortunes rise, their health will be better for various reasons — or you can promote better health."
While it is true that to some degree people's health is determined by lifestyle and genetics — not their access to health care — there are still people "who have catastrophic health problems no matter what," she says.
There are people who maintain healthy lifestyles who — due to genetics or environment — develop catastrophic diseases.
"You need to make sure that the treatment you have will enable you to either be cured of this disease, or to live with this disease," Berlinger says. "But it's not an option not to have health care in those cases."
Physicians should be concerned with this — not only because by definition of their profession, they are in an ethical relationship with their patients — but also on a very practical level, Berlinger says.
"I used to have a colleague who would say, 'It comes down to, do we believe people should die in the streets or not? . . . If you don't think people should die in the streets, you're going to have to figure out how you're going to pay for their care.'"
But then questions arise, she says, like, "Who is going to pay the doctors? Should the doctors work for free? Well, maybe we don't think that. So, if we need to train the doctor, and the doctor needs to get a paycheck, who is going to pay for it if this person who would otherwise die in the streets can't afford to pay?
"What do we do? We call that safety net, charity care, unreimbursed care. We have policies like EMTALA," she notes.
To the question of whether access to health care is a human right, Berlinger responds, "Here's what a lawyer would say, [and] I mean that in the best possible sense: A human rights lawyer would say that 'a right isn't a right unless it's actionable.''
"It can't just be that somebody tells you you have a right," she explains. "Because somebody else might say, 'Well, how do I get that right? How do I use it in practice?
"We can't just say it's a right — it's out there somewhere and maybe someday you'll get to use it. No. You have a positive obligation to help people use their rights."
Berlinger maintains that it's not enough to say health care is a right.
What are reform options?
Robert J. Barnet, MD, MA, a cardiologist and senior scholar at the Center for Clinical Bioethics at Georgetown University in Washington, DC, suggests as one option medical cooperatives.
Like many, one of his primary concerns is the lack of meaningful access to basic health care for millions in the United States. He suggests undertaking health care reform that: prohibits denial of coverage for pre-existing conditions; prohibits the discontinuation of coverage with illness or loss of employment; and establishes nationwide portability.
Barnet also suggests "meaningful" malpractice reforms that: establish national standards; establish a cap on pain and suffering; recognize the potential benefit of a Medicare-like health care system for children; and tighten rules for expert witnesses.
Sources
- Robert J. Barnet, MD, MA, FACP, FACC, Senior Scholar, Center for Clinical Bioethics, Georgetown University, Washington, DC.
- Nancy Berlinger, PhD, MDiv, Deputy Director and Research Scholar, The Hastings Center, Garrison, NY. E-mail: [email protected].
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