The Health Care Debate

This has been an interesting week in the blogosphere. The debate over Health Care, whether it should be universal, whether it is a right, and how or why we would strive to enact it has been healthy. I’m incredibly interested in this and have been reading as much as I can. What follows is a synopsis of the debate as I have seen it. Throughout, something has not been sitting well with me, and that I finally figured it out is why I’ve brought these excerpts together. My conclusion is at the end.

Kevin M.D. posted this under the heading “Health Care is Absolutely Not a Right.” The comments that follow are fascinating, and I would encourage everyone to read through them.

This is the fundamental philosophical difference between what I (and others) believe and the stance of the single-payer supporters. Thanks GruntDoc for linking to the money quote:

As with any good or service that is provided by some specific group of men, if you try to make its possession by all a right, you thereby enslave the providers of the service, wreck the service, and end up depriving the very consumers you are supposed to be helping. To call “medical care” a right will merely enslave the doctors and thus destroy the quality of medical care in this country, as socialized medicine has done around the world . . .

The debate that followed in the comments circled around the EMTALA law, which mandates that any hospital must accept emergency medical cases, regardless of ability to pay. Hospitals abide by this law at considerable loss because the governement has threatened to remove funding for any hospital that does not. This would mean loss of Medicare, Medicaid, etc. One poster, Okulus, had the best comment:

In my view EMTALA is bad law. It mandates services under the threat of withdrawal of funding for unrelated services, which is extortion, particularly given that the taxpayers are providing that funding. (No different than threatening to take away a state’s allocation for highway subsidies if that state fails to comply with an unfunded mandate regarding education). Certainly I have a right to vote for candidates who want to repeal EMTALA. But even if I didn’t, that does not make EMTALA any more a good law. And it doesn’t make expropriation of services a right.

So is health insurance a right? Of course not. It is neither a de facto nor de jure right. And neither is postal service or 911 ambulance service or sewage disposal. They are services, available to the public when the public chooses to pay for them, and the converse when not. Any one of them could be here today and gone tomorrow, unlike real rights, which are far more durable.

So with the link to Graham Azon’s blog as the “single-payer supporter,” he responded with a two-parter (1)(2). These excerpts are truncated, so for his full argument you should visit his site:

Honestly, I think many people in the media use “socialized medicine” as a scare term, a blanket term for any sort of “government” health care. If that’s how you’re using it, fine, but if you’re presenting information as policy arguments, you sound a little sophomoric if you use it incorrectly. (This is like referring to the rectum as “the poop chute.”)

Socialized medicine is what the UK has.

Socialized insurance is what Canada has.

“Pay or play” is an employer-based system, where employers either have to offer coverage, or contribute to a fund to provide coverage to the uninsured.

***

From where I’m standing, then, if we’re going to take care of the acutely ill, we might as well keep societal costs lower by preventing people from becoming acutely ill (or from developing the consequences of chronic illness). Am I crazy? Am I missing something here? You can’t tell me that our system makes sense in this way. We will allow an uninsured diabetic to go years without any preventive care, because lack of ability to pay, but once his foot becomes necrotic and he needs an amputation, and gets an ICU stay for becoming septic–oh well, let’s definitely pay for that!?

Look, if you have a problem with the “political feasibility” of single-payer, that’s fine, we can debate that. If you’re weary of allowing a government entity to set all health care reimbursement, that’s fine, we can debate that. But to stick your thumbs in your ears and ignore that we’re already ready to pay for emergency care, because of the consequences of the alternative is just stupid, plain and simple.

So, what’s your better solution?

So from all of this, it strikes me that people are either holding steadfast to their philosophy that no resource can be mandated as a right (as that necessarily limits the rights of those providing the service), or they are holding steadfast to their pragmatism (that leaving people with their injuries because they cannot pay is not something that we are comfortable with as a society, so let’s fix that). I like Graham’s challenge though: what is the better solution?

So here’s mine.

FUND EMTALA. The Emergency Treatment and Labor Law was enacted in 1986 as a response to the act of “patient-dumping” by hospitals. In essence, the statute:

  • imposes an affirmative obligation on the part of the hospital to provide a medical screening examination to determine whether an “emergency medical condition” exists;
  • imposes restrictions on transfers of persons who exhibit an “emergency medical condition” or are in active labor, which restrictions may or may not be limited to transfers made for economic reasons;
  • imposes an affirmative duty to institute treatment if an “emergency medical condition” does exist.

That last bullet point costs money. Lots of money. Where does it come from? EMTALA is an unfunded mandate, meaning that it was decided that providing medical care was so important that it required a law to be passed to ensure it, but not important enough to be supported financially. The weight of this law rests inapprpriately on the hospital, not where it belongs on the taxpayers whose interests are represented in Congress. Why would any hospital agree to this? The guillitoine of severed Medicare payments should they not comply.

Unless you run a hospital, why should you care? Imagine a hospital that is running without making a profit. They make enough money to cover all of their expenses and meet all of their salaries. Everything is only as expensive as it needs to be and all the prices charged are fair. If this hospital had to abide by EMTALA, it will begin to lose money. It’s options at this point are to ignore EMTALA (in which case it loses money anyway as the governemnt withdraws payments for patients on Medicare), go bankrupt and close (happens way more often than you think), or make up the loss by charging paying customers more.

I give you the $10 tylenol. Now we can debate the many factors for the rising costs of health care until we’re too dead for it to matter, but the fact that a hospital that abides by EMTALA must then overcharge paying customers is inescapable. It is also unfair. If you cannot pay for your own healthcare (and receive it anyway because of this law), then you are making healthcare more expensive for those that can pay. If this doesn’t happen, then the hospital closes and you’ve not only lost that resource, but you’ve stressed the remainging hospitals that now experience increased patient loads.

I give you a downward spiral. So for anyone that will ever need hospital care, this does matter. The solution seems pretty straightforward to me, and that is to reimburse the hospitals for their costs. It makes no sense to demand that hospitals pay for your service so that it is free to you. If we are as serious about giving everyone care in an emergency regardless of insurance as we claim to be, then that requires a serious sacrifice on our parts. Our taxes are going to increase. You will have, in effect, given universal accident insurance to the nation.

The details of payment can be left to the hospitals and lawyers to discuss, but the hospital should be able to demonstrate its expenses and the US government should send a check in the mail. So that’s my first solution: fund EMTALA.

Of course, what happens next would be interesting. If hospitals were able to do this and still saw all of the current cases in the ER, they would likely welcome the non-emergency cases that they currently detest. If the governement (and by that I mean all 300 million of us) were to see the bill, there would likely be some sticker shock. “We can’t afford to fund EMTALA,” we’d realize. “We’ve got to figure out a way to keep these non-emergency cases out of the ERs,” we’d decide. And it’s because we would likely be pushed into this future that I like Graham’s second point.

To paraphrase, emergency cases cost a lot of money, and these emergencies are sometimes the result of an uncontrolled chronic condition (amputation of a diabetic’s foot) that could have been prevented at a much lower cost. So if we’re going to have a funded EMTALA with effective universal accident insurance, wouldn’t the taxpayers save even more money with universal and comprehensive medical insurance?

I stumble with his conclusion. Not every American presents to the ER, and while providing preventative care for the person that does would save tax dollars, I can’t know which person’s preventative treatment to target. In other words, universal medical insurance has perfect sensitivity but poor specificity. It seems to me that any preventative measures should be specifically targeted and if that was truly cheaper the investment would be worthwhile.

Joe Paduda at Managed Care matters has a good point and I’ll let him have the last word. He’s absolutely right that we have to define our goals and these have to be in line with our principles. So in the interest of openness, I’ll be very specific about mine:

No one can claim a right to anyone’s service. It follows, then, that health care is not a right, but a want. It also follows that the weight of any proposed solution should fall on the backs of those who benefit (the tax payers) and not on the backs of those that provide it (hospitals, physicians).

No one can arbitrarily decide the worth of a service. By capping what a physician (lawyer, artist, whomever) can charge for his service, you are robbing him of his value and destroying the distinction between good and bad service by removing its incentive. It is for markets to decide what a service is worth, not governments.

I am open to (and would support) any program that successfully makes health care more accessible while not conflicting with these first principles. It remains to be seen if Single Payer is the solution to this, and I think everyone is going to be very interested with the results from the single-payer experiments in Main, Mass, Maryland, etc.

Joe Paduda’s last word at Managed Care Matters

What are we trying to accomplish with health care reform?

Lower costs today? A sustainable trend rate so care is affordable for the foreseeable future? Better outcomes, defined as healthier people and/or fewer avoidable deaths and/or higher levels of functionality? Coverage for all so no one goes without? Equitable reimbursement? Less interference in the doctor-patient relationship? Greater self-responsibility on the part of consumers? A reduced financial burden on employers, especially small ones and really big ones with lots of retirees? Ever healthier, longer-lived citizens?

All of the above?

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12 Responses to The Health Care Debate

  1. Kim says:

    What a fantastic overview/consolidation of different viewpoints! I posted on the same thing (nowhere near as well), and I agree that the majority of health insurance needs to focus on primary care and the prevention of problems before they blow up into emergent situations. My take on how to pay for it may or may not be doable, but something must be done.

  2. Well done! I am quite interested in your “Fund EMTALA” idea… why not couple that with sending non-emergent ER visitors to retail clinics staffed with nurse practitioners? It’s cheaper and more convenient… Of course, my problem with this is potential erosion of the “medical home.” But if the retail clinics partnered with family physicians… it could become a low acuity satellite/ancillary service for docs. As usual, many pro’s and con’s with no clear best answer.

  3. Kurt says:

    We continue to refuse to accept the time-tested adage that in healthcare, we all want low prices, fast service, and quality care, but we can only have two of three–and must choose. We keep believing that there is some technical fix around this unpleasant feature of grown-up life. HMO’s were going to save us in the 70′s, capitation in the 80′s, and market forces in the 90′s. Now the new savior is going to be IT. Like lemmings over the cliff, we follow–ignoring the consistency with which all previous fixes have been marked primariy by unintended and unpredictable consequences and costs. Hasn’t anyone noticed that all of the industrialized countries healthcare sectors are severely strained now? Clearly there are things going on here beyond nation specific structures.

  4. Jesse says:

    The EMTALA funding was a good illustration of the economic principle that the corporate tax is, in essence, passed on to the consumer. In the EMTALA case, the ‘tax’ is the law that requires treatment regardless of the ability to pay. Where your argument is flawed, is that you rectify this ‘tax’ by imposing a real tax. This does nothing to shift the burden which still lies on the consumer (consumers pay federal income tax).

    A more important consideration in this healthcare debate is how silly it is that most consumers have no idea how much healthcare really costs. Until this happens, market forces will not have a real chance to fix the healthcare problem. Milton Friedman wrote on this extensively.

  5. Jesse, I disagree with your assessment. In the present case, everyone benefits from the effective EMTALA accident insurance while patients (both emergency and not) are charged disproportionately, to speak nothing of the squeeze placed on the providers of that care. By instead funding EMTALA, everyone still benefits from the effective accident insurance, everyone is charged proportionally, and the providers of care are not carrying an unfair burden. The goal was not to “shift the burden which still lies on the consumer” from the consumer. It was instead to distribute that burden among those that benefit (all those insured, whether they use it or not).

  6. Jesse says:

    Fair enough, my assessment was indeed incorrect based on your goal.

    However, the effect would seem minimal. The fairness would lie in the belief that there is a portion of the population who does not visit a hospital and pay for things, but who are still technically covered under EMTALA (because they have the capacity to seek free treatment). This is a poor assumption, I believe, because we will all inevitably seek care at some point. To clarify, the burden already seems well distributed.

    This law has been described as everything from unfair to unconstitutional, and what I find wrong with funding it is that it actually gives hospitals incentive to give free treatment. I would describe this as a bigger problem, and not a solution.

  7. Jesse,

    If you have no money, are hit by a car, and then present to the ER, you benefit from EMTALA as it ensures your treatment even outside of ability to pay. If you have money, are hit by a car, and then present to the ER, you benefit from EMTALA as it ensures your treatment even while you cannot demonstrate your ability to pay (because you’re unconscious). I am not making an assumption when I say that people not currently using the emergency room benefit from EMTALA; it logically follows.

    Before EMTALA, a patient presenting would be checked for ability to pay and if there was no money, the patient was dumped by the hospital. EMTALA reduces your risk of this very negative outcome. If you cannot see how having this reduced risk under EMTALA benefits you (and everyone else), I cannot help you understand it further than this argument.

    The burden is not “well distributed” if sick people pay for the benefit that everyone enjoys instead of everyone paying for the benefit they enjoy.

    That we “all inevitably seek care” is not the same as seeking emergency care, and I cannot imagine that you are making the argument that we will all eventually seek emergency care or that each individual’s burden on the system is equal, both of which would have to be true for your argument that the burden is “well distributed” to be taken seriously.

    That you think funding EMTALA would give hospitals incentive to provide free treatment completely misses the point. The hospitals are already giving free treatment because of an unfunded-EMTALA and are overcharging others to cover it. If you instead meant that funding EMTALA would give hospitals an incentive to provide unnecessary treatment, this might have been more on point. This outcome, along with its consequences, was already covered in the above post.

  8. Jesse says:

    At the risk of belaboring the point, let’s keep this going…

    Asserting that we all inevitably seek care is not necissarily saying we all seek emergency care, but any care that could potentially subsidize EMTALA. This is the $10 Tylenol that you mentioned in the above post. Therefore, the burden is already well distributed. Your argument is that the people who are extra sick will have to pay an unjust portion of this burden. Fair enough, but EMTALA is the least of these people’s problems. Keep in mind they are also paying an unjust burden of all the inefficiencies of the U.S. healthcare system, and these far outweigh those created by EMTALA. Not to mention the fact that they are far less ethically acceptable.

    Ultimately, I gather your beef to be with the U.S. government and their unwillingness to fund the accident insurance that it imposed. In reality, EMTALA just solidified in the form of a law the idea that hospitals have a fiduciary duty to treat the sick in times of an emergency. The cost of this care became a business expense of the hospital. By changing things and blindly writing checks to emergency rooms for all the free care they can dish out will do nothing more than extend the government’s hand in funding individual healthcare. This was not the goal of EMTALA, and if that is what you truly want, you are going to need another law.

  9. I appreciate your interest, but I’m exhausted by this. Your arguments are ad hoc, strung together not by sound premises and logical progression, but connected instead by the conclusion you insist on reaching. I’ve taken the time to carefully respond to your previous two posts with well-reasoned points and that effort is not being returned. In light of the lack of progress, I’ve lost my interest in continuing this debate with you.

  10. I found what I was looking for,easy to read, gave me some great ideas

  11. CHenry says:

    Jesse, your argument is significantly off the point. The burden is disproportionately distributed to those who have the private means to pay. EMTALA is a “robbing Peter to pay Paul” scheme, the robbed being the unpaid hospital, the unpaid doctor and the overcharged private patient of the hospital. And your argument about the greater burden of system inefficiencies somehow obscuring and negating the injustice of EMTALA is akin to your arguing for the right to dump trash in your neighbor’s yard because he neglects to cut his grass. It is irrational at its root.

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