two thoughts on the state of healthcare in the united states

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Over the weekend, I got a chance to talk to Elli. He was attending the 2010 Missouri State Medical Association Convention, and mentioned listening to a doctor-turned-state-representative who essentially argued that healthcare is not a right. Upon further investigation of the topic, I came across this editorial (not from the same person, I assume); the author suggests healthcare is not a right because the rights that we’re guaranteed under the Constitution (life, liberty, and the pursuit) are rights to action, not rights to reward. Interesting points, but I really take issue with this paragraph:

The battle against the Clinton plan, in my opinion, depends on the doctors speaking out against the plan -- but not only on practical grounds -- rather, first of all, on moral grounds. The doctors must defend themselves and their own interests as a matter of solemn justice, upholding a moral principle, the first moral principle: self- preservation. If they can do it, all of us will still have a chance. I hope it is not already too late. Thank you.

Moral grounds? Self-preservation as the highest moral value? His argument unravels there. Self-preservation is certainly not my highest moral priority, and nor do I think we are being morally sound to deny healthcare to citizens who can’t afford it. Although we should pay for the goods and services we use, society collectively helps to educate its citizens for the betterment of the society as a whole, and doctors are no exception. Additionally, the externalities that all of us gain from having a healthy population far outweigh the costs to the individual.

Unrelated, but equally thought-provoking: regarding fee-for-service models, from the New England Journal of Medicine, in a roundtable with the well-known Atul Gawande and Dr. Elliot Fisher of Dartmouth Medical School, among others:

Fee for service does not pay for us to have long conversations with our patients. When we're feeling constrained, it's much harder for us to have that long conversation with a patient with heart failure to see if we can safely manage them at home. The default position in many communities becomes, "Gosh, I'm too busy. I better send them to the emergency room." The emergency room physician recognizes that they don't have time to manage the patient with heart failure in the emergency room, so admits them to the hospital. To the extent that those resources are available for us and we're not paid to do the things that we really would like to do or know we should do, we see huge differences in the likelihood of really unnecessary hospitalizations in different communities.

Dr. Fisher sums up the problem well – we incentivize doctors to spend less time talking to their patients and more time trying to comply with 80+ agencies’ regulatory and compliance requirements, and trying to keep their practice afloat. The practice of medicine in our society, in other words, is about so much more than patient care.