Is health care a right?

28

Category : Medical Rants

I cannot even pretend to be an amateur philosopher. I am more than willing to express my opinions, but my thought processes are not rigorous enough to work through a thorough philosophical argument.

We do have a conceptual divide in our country (and probably other countries). Some thinkers consider health care a right. If health care is a right, then we should provide the highest quality health care to all citizens, regardless of means. Some believe that “basic” health care is a right, but that we can ethically provide different levels of health care according to the patient’s ability and willingness to pay.

Is health care a “right?” (link first seen at KevinMD)

OK, that’s not too bad, though it starts intruding on the employer/employee relationship.

Article 25.

(1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

(2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

Where did that come from? Huh? All of a sudden we’ve gone socialist in a single clause (1)!! And that’s the clause where the difference between liberals and conservatives is manifested.

Conservatives believe you have the right to seek food, clothing, housing, and medical care, on an equal basis with anybody else, but you don’t have a right to demand those things or have them provided for you. Liberals believe that until all people have these things, redistribution of wealth is mandated by humanitarianism, because these are fundamental human rights.

In some ways one could construe this as a difference in Golden Rules.

Is the Golden Rule – Do unto others as you would have them do unto you. (attributed to Jesus) or This is the sum of duty: do not do to others what would cause pain if done to you (a Hindu version attributed to Mahabharata)?

Read these rules carefully. Do we want an active Golden Rule? Should we proactively help others? Do we have an altruistic philosophy?

Or do we have a passive Golden Rule? Is our obligation not to injure others, rather to to proactively help them?

I submit that these are different ethical views. Some would argue that one is superior to the other, however, I suspect one could construct solid arguments each way.

For those who want to consider this subject more deeply, I would suggest this web page on the Ethics of Reciprocity – SHARED BELIEF IN THE “GOLDEN RULE” – Ethics of Reciprocity

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Comments (28)

I am not much of a thinker but….

The second version says not to hurt others. However is ignoring thier suffering actually hurting them indirectly? By allowing them to be in pain, are you further contributing to thier pain, thus violating both rules?

I don’t think it is an easy question for a logical approach to answer.

There is a clear difference between the two ‘rights’. My right to life doesn’t hurt your right to life. My right to liberty doesn’t hurt your right to liberty. My pursuit of happiness (to most extents) doesn’t hurt your pursuit.

On the other hand, if I have a right to a certain standard of living (health, etc.) and am unable or unwilling to obtain that standard through my own efforts, then I essentially have the ‘right’ to take away things that are the product of your efforts. My ‘right’ to a standard of living hurts your standard of living against your will.

Now if you pursue happiness in part by giving from your excess to others in need, wonderful! But coercing one group to do things that meet another group’s standards is the road to authoritarianism.

I rather frame the issue as who do we allow to be burdened by the lack of basic health care for all? From that perspective it doesn’t take long to realize that we are all sharing this burden. We share it through our prison system which doubles as a mental health system. We also share it through the many methods that are used to ensure people, especially the workforce, are productive.

NO- healthcare is not a right !

BUT a free market, open dynamics is…

There exists market demand for high quality, low cost healthcare… artificial scarcity does little for health achieve this goal.

As always, the question needs to be rephrased: is open society a right? is anti-trust legitimate? are free markets a right? who benefits from inadequate provider numbers?

These are the questions that must be addressed, not is X a right?
is eating an ice cream cone on a hot summer day a right… NO! but its damm nice, and sellers figure that providing what consumers want makes it all the easier to make a sale .

I suggest learning from the similar issues around food, which is far more crucial than healthcare and where much more nuanced conclusions have been reached.

In most countries, providing food to eat is treated as a social obligation. The mechanisms vary and overlap, incuding charity, welfare, subsidy, etc. They also include substantial means testing. The obligation tends to be of the form: “If you can show that you have no ability to obtain food, then society will provide a minimal level of sustenance. If you want better, or are able to provide your own, it is up to you not society.”

US regulations have substantially reduced the charitable healthcare organizations due to unintended side effects of Medicare regulations, but some charitable aid still exists. Medicaid does exist. There are subsidies.

Much of the “rights” argument becomes the question of how minimal is acceptable, and how much should be up to the individuals. With food the means tests arguments are recognized as such, not as a “rights” argument.

To connect this back to your note, there are two situations of “Do unto others … ” at work. If I am starving, I would want others to provide food that I could survive. If I have food, I would not want someone else who also has food (or wants better food) to take mine. But I am willing to provide food to those who would starve otherwise.

People can pay for health care on their own buy health insurance or obtain it through their employer. Society provides healthcare for the poorest through the means tested Medicaid program and to the elderly and certain others through Medicare largely, though not completely, at taxpayer expense.

Since our society will not let people literally die in the street or outside of the hospital ER for lack of health insurance or a means to pay, the question becomes: to what extent should the 46 million people who currently lack health insurance be allowed to impose the cost of their healthcare on society? If a significant number of these people could afford to purchase at least a high deductible health plan, they should be required to do so. If they can pass a means test and don’t already qualify for Medicaid, taxpayers should probably provide subsidies sufficient to allow them to acquire adequate health coverage.

To control healthcare costs, which already consume 16% of GDP, there are basically three challenges which can be summarized as follows:

(1) Administrative efficiency – Streamline and standardize coverage offerings and pricing of services. Provide good price and quality transparency to help both providers and consumers make rational choices as to what care they get and from whom.

(2) Utilization efficiency – Minimize unnecessary visits to the doctor, unnecessary care by doctors (defensive medicine) and excessive or futile care at the end of life.

(3) Practice efficiency – We need robust electronic medical records to minimize duplicate testing, adverse drug interactions, etc. while decision support tools and evidence based medicine could help doctors maximize the effectiveness of the care they provide.

I practice a form of naturopathic medicine that’s heavy on coaching folks in the things they can do themselves to address their medical conditions. I’ve been doing this a long time; for the last three years I’ve been privileged to attempt these methods on patients in the pain management dept of a very large and famous orthpaedic clinic.

They work. But they demand changes in lifestyles (particularly food) that many folks are reluctant to make.

I’ve always been conflicted about this whole issue of the “right” to health care. In my experience there’s a very clear pattern … people who pay me for their care out-of-pocket are much, much more likely to implement the changes in their habits that are necessary to address their condition … and get much better outcomes as a result. People who rely on third-party payors to pick up the tab are much less likely to do their part.

In most other areas I consider myself a lefty … but I’m not quite sure what to think given this pattern.

Recent surveys report that most people think health care should be a right. Most of the people who lack health insurance are working. Their employers may not offer any health insurance plan or offer a plan with a higher premium than low-wage workers can afford (think minimun wage of $5.15). It’s true that hospitals may not refuse to provide emergency care to anyone, but getting to the point where you need emergency care could involve debilitating illness or disability. So emergency care is not very efficient, and it’s extremely costly.

The free market hasn’t worked very well in health care. Consumers have few tools to enable them to make informed choices about providers, and if you’ve ever had a serious condition you know that it’s not a good time to sit down and research doctors who provide good care at appropriate prices. Information about malpractice and malfeasance is difficult if not impossible to obtain, and comparing fees is out of the question.

BC outlines above some of the deficiencies in our health system. I don’t agree 100%, and there are always tradeoffs–for example, single medical records are a great idea but it would be very difficult to build in an effective mechanism for confidentiality. And typically one doesn’t know whether a doctor’s visit is unnecessary without going to the doctor to find out.

What does work: so-called Centers of Excellence, where hospitals specialize in a narrow range of procedures and do a great many of those, tend to provide much better care with much better outcomes than hospitals that do everything but nothing very often. Evidence indicates that even if patients have to travel long distances to these facilities they are still more cost-effective. Nurse-practitioners, nurses and physician’s assitants can provide a great deal of routine care, letting physicians specialize a bit more and learn to do one thing well. Some forms of preventive care are very cost-effective, but other commonly accepted preventive procedures aren’t. There are plenty of health economists out that who could sort that out–if they haven’s already. And what consistutes “continuing medical education” should be looked at.

I recently read on the NIH website that the US collectively spends $200 billion on health care each year. What is the population–about 500 million? Do the math–that’s a lot of money, especially if a large number of the population is excluded . Surely we can do better.

To the poster, above, I see a better argument here for raising the minimum wage than for making health care a right. More pay at least would improve the means for buying health insurance. The issue of overuse of emergengy rooms for non-emergent care is a result of several factors, including lack of acceptable insurance coverage. It is also a result of patient exploitation of EMTALA as well as sloth , poor personal planning and poor use of available non-emergency resources.

Concluding that the present collection of pathways to care–a system for some but not so much for others–represents a failure of free-market economics as concerns medical care is plain error. The one thing the present system is not is a free market. It is an ungainly collection of closed-market mechanisms, quasi-monopsony, filled in at the edges with cash-pay under poorly transparent conditions and outright government-sanctioned expropriation. It may be right to call it a failure or a dismal form of success, but a free market it is not. Information about malpractice, if we are to believe the occasional opponents to tort reform, should not affect much the decisions patients make about how they use health care services.

Single medical records are a red herring. Their utility first presumes that patients go to the doctor and that when they do, they follow their care plans. Much of the drum beating about single medical records is really beating up support for large-scale utilization of software products designed to support that kind of initiative. It will possibly simplify recordkeeping for frequent utilizers of medical services and their doctors. I won’t likely affect the more global drivers of costs–longer living in advanced age with increasing use of care, new but costlier innovations in treatment and the burdens of caring for disease resulting from long term poor choices in lifestyle. Privacy pales as a significant concern, and the proposed savings in redundant testing and medical error reduction, while desirable probably will not represent all that much an offset in costs associated with overall consumption we will inevitably face as a nation.

The Centers for Excellence idea is another OK idea, but doesn’t really represent the solution it claims. As centers where leading ideas can be tested, or new technologies launched and studied, or standards of best practices developed, they are fine. But to expect long-distance travel to ultra-specialized centers as the primary method of receiving state of the art and economical care is just an utterly benighted concept. It totally fails to see the problem of access from the ground, that quality care must and should be available locally, and that best practices and standards need to diffuse out to where patients can be served near where they live, not piecemeal in specialist hospitals dotted around the map.

The U.S. population? By the best guesses of the Census Bureau, it just passed the 300 million mark about six weeks ago. We should hit 400 million before middle this century.

Do onto others as they, themselves, would like to be treated.

That is part of the Golden Rule as well.

Actually, there is little debate politically about whether health care is a right. All sides of the political spectrum believe that EMTALA should be continued. The Republicans have been in power for 6 years and have not even murmured about repealing it. Be sure the Democrats won’t. So there is widespread agreement that having some degree of health care coverage is a right.

Thus, we already have socialized medicine. We just have a really crappy version of it that doesn’t understand what it is and tries to be something else.

If people really believe that health care isn’t a right, they will lobby for hospitals, doctors and emergency rooms to be able to refuse care to people solely on the basis of ability to pay EVEN IN AN EMERGENCY!

If a person really believes that health care is not a right, it should pose no problem to them that people are being denied medical care when they are having a stroke, heart attack, ruptured aneurysm, et cetera … not even picked up by the ambulance … if they have no insurance.

Obviously, nobody who has any power in the US thinks this should happen.

So stop worrying about how terrible socialized medicine is. We already have it. We ought to be trying to improve the socialized system that we have.

I agree with the gist of that last comment – we as a society have effectively declared that we will provide at least some level of health care service regardless of ability to pay (and the current system does a crappy job of distributing those services). We’re mired in the crappy status quo because nobody wants to take responsibility for the hard choices necessary to move us forward.

Let’s say, for example, that you created a basic health insurance plan that would be available to all people, which replaces Medicare and Medicaid, and probably displaces a wide range of crappy health insurance plans currently offered to low and lower-income workers. At what point do you say “You’ve received your quota of care, and if you can’t pay for the rest yourself you’re out of luck.” Such a system would likely work better for people who are presently underinsured, for those who get supplemental health insurance coverage from their employers, or for people who are affluent. But in many cases it would provide less care to people who are on Medicaid, as well as potentially creating gaps in coverage where we as a society would still not be prepared to literally let people die because they could not afford to pay their balance.

Take premature babies as an example. Would we truly set a cap on medical costs, and let babies die if their parents could not produce more money? Take a child with cancer – same question. And what about end of life care – at what point do we tell the elderly patient that they can live perhaps for three years if they have the cash to pay for care, but otherwise they’re being cut off? In a sense it’s easier to do this, or to relegate their care to a charity, when there’s not a national health care plan – because then the fault lies with somebody or something other than the national health care plan, and it’s “somebody else’s problem to fix”.

I think we would be better served if we did the following:

1. Keep the Medicare and Medicaid programs as they are now.

2. Partially replace employer provided coverage with a catastrophic coverage tier that would kick in once expenses passed, say, $50K in a year. This coverage should probably be publicly funded by a payroll tax.

3. Employers could then provide coverage below the catastrophic level at much lower cost whether they self-funded or purchased coverage from an insurer knowing that there was the publicly funded catastrophic coverage tier to pay for the very high cost cases. Also, small employers would be much more likely to be able to afford to provide coverage for their employees. Self-employed people would be able to purchase coverage at much lower cost than under the current system as well.

4. People in the top half of the income distribution could buy high deductible plans for a very affordable price as could young, healthy people who think low deductible coverage is just too expensive.

5. For the high cost cases, especially the end of life situations, we need to evolve a consensus as to what constitutes good medical practice. Perhaps QALY metrics could be part of the equation. We could evaluate what our friends in Canada and Western Europe do. We could also make executing a living will and/or an advance medical directive a requirement to get insurance.

6. EMTALA related costs are probably not that big a factor in the overall scheme of things, but to the extent that we can require people to purchase insurance if they can afford to or obtain it through their employer, we should.

This is a wonderful discussion.

I was about to quote Rabbi Hillel’s Golden Rule, but I see you already have it right there in the right sidebar. “What is hateful to you, do not do to your neighbor.”

Margaret: “The free market hasn’t worked very well in health care.”

But our current system is nowhere near a free market. The government’s share of healthcare spending, counting Medicare, Medicaid, and the subsidy of buying insurance with pre-tax dollars, amounts to over half of all healthcare spending. So we’re actually closer to a single payer socialist system than we are to a free market.

The wisest thing I’ve read on this topic was written by the recently departed Milton Friedman: How to Cure Healthcare. It’s a good essay. All the rest is commentary. Go and learn it.

Drat. My link didn’t work. Must try again.

How to Cure Healthcare

It seems to me that the idea of the Common Good has been lost on many conservatives who oppose “socialized medicine”. There are some basic facts as to what makes a society succeed or fail that need to be addressed by adopting a basic level of universal care. Everyone should have the ability – even obligation where no medical contraindications – to receive certain preventative care such as vaccines, treatment for contagious diseases, etc.

There are plenty of people who could become single disease vectors due to their inability to pay for basic care. A repeat of a deadly flu epidemic is the most likely scenario. It would start with a working class child getting the flu that mutates and is then caught by family members who cannot miss even a day of work contaminating their co-workers who in turn contaminate their families. See the vicious cycle? The old Kevin Bacon game on the Internet was an excellent example of how diseases travel.

The flu could cripple the economy quite easily. People in the early 20th century shut down their businesses and some who would not have died died due to there be no one who could care for them.

Let’s take it away from the dire circumstances of a deadly epidemic into a very common chronic disease. According to many studies, 25% of all Americans suffer from allergic rhinitis. (I have not investigated the veracity of these studies.) There are several studies that show that there is a very large economic cost to untreated allergic disease in terms of lost productivity. We have cost-effective treatment for the majority of sufferers. Many people do not treat their allergies due to the lack of proper care management.

Another ongoing issue is the rise in hormonal problems including thyroid disease. If someone’s thyroid is malfunctioning it often includes brain chemical imbalances. (You would think that is a no-brainer, as they say, but many doctors to this day do not take this symptom seriously.) If someone cannot think straight they cannot contribute to society.

This is just the _practical_ societal cost of not treating the basic, underlying issues.

There is a great deal of truth to the fact that insurance is the single biggest contributor to the overall cost of medicine. The insurance companies are double- , even, triple-dipping into the costs via medical insurance, individual malpractice insurance, and institutional malpractice insurance. (And, if you are lucky enough to be in a situation where you manage multiple institutions, insurance companies will find a way to bill you every which way.) Let’s not even get into the costs of having to have huge billing staffs in order to attempt to get claims processed! Legalizing racketeering was a mistake.

I think thinking of this as a “right” vs. something needed for the public, or, “common good” is a mistake. There is a basic level of healthcare that is needed to sustain the public good.

As to free market economies and healthcare, the only real example is ART (Advanced Reproductive Technology). I haven’t had an opportunity to yet read the new book on ART as a market force, but it is on my list of must-reads. From what I’ve read in reviews and discussions, there seems to be a divide between those who are offended by the marketization of reproduction and those who see this as a victory of the market. (Yes, I know this is a simplification, but one has to start somewhere.)

Pax,

MLO

Just for clarification,

you guys seem unaware of how difficult it is to qualify for public assistance. You classify poeple into poor-thus qualifying for medicaid- and others-too lazy, slothful, ignorant, neglectful or cheap to buy health insurance. Perhaps you guys should make a trip back to reality now and then.

In texas:

It is pretty easy being a single mom to get your kids on medicaid or while pregnant. The mother is covered up until birth but gets kicked off shortly after that. Then programs like WIC and planned parenthood help deal with routine exams and birth control. Society has ordained that this is for the public good.

To even get this you have a six hour wait at the medicaid office. Then monthly appts in which you wait another four to six hours to see a counselor to recheck your paperwork.

It is almost impossible to get on medicaid any other way. A single adult would have to be unemployed, asset free and homeless to qualify for medicaid, food stamps or welfare.

If you as a single adult make 10 grand a year you are not covered by medicare and you sure as hell can’t afford health insurance at 250 a month. You get NO health care unless you show up at an ER.

In a large urban county-say Dallas or Ft. Worth, if you show up at the ER of the public hospitol enough and spend about 25 hours waiting and filling out paperwork, then you may be eligible to start seeing MDs outside the ER. This is tricky as you need to get to the clinic they assign three to five hours in advance of the time it opens to sign in, or you might as well go back home. Once you learn to work the system then you can find ways to get meds covered sometimes and see MDs within several months time for chronic conditions. You really need to be unemployed however because no working person can sepnd six hours a day waiting for an appt even if they manage to sneak in the back door of the system.

I think you guys live in the imaginative world of the wealthy. Most of you and your parents grew up in middle to upper middle class families and have little idea what it means to be poor or not be able to provide your children with food and housing let alone health insurance. Poor people just need to work harder, or save more, or plan better and they wouldn’t be poor. They should suffer for thier own decisions. Because you have never been poor yourselves.

Why is it you are all so blind to the most obvious problem with heatlh care??? Are you in denial?? All these cute remedies and excuses and blame don’t fix the problem. They are straw men, to borrow DB’s terminology, to cover up the real problem.

Health care is never a basic right.

Tina, you improperly assume the role of the scourge.

My background, about which you assume much but know nothing is irrelevant. I have worked and when uninsured, have eaten the cost of carrying my own insurance without anyone else buying it for me. I paid for that insurance even when I didn’t earn enough to own a car (yeah, I took the bus and rode a bike). So can your presumtuous lectures about not knowing anything about making do with very little. I’ve been there and done that. And I can tell you that many of the barriers to care faced by people you think of as “poor” are self-imposed, not all of them, but many, still. Also, doctors still accept cash for services, usually at a discount to insurance (no, that does not mean cash payment over time). Even without insurance, you can still buy care for ready money.

I paid for my education and bear the business costs of my practice and have every right to expect those who come to me for my services to pay me. I really don’t care whether they think of health care as their right, as long as they pay their bill. But those who think they have a right to my woirk without paying me can take a hike. Those are the same sorts of folks who would scream bloody murder if someone shorted them their pay.

Hi Tina,

YOU ARE NOT ALONE… middle america is groaning under the weight of supporting the medical cartel/rent collection. Barriers placed on the greater public and market are not at all “self-imposed,” period !

some tips to fight back:
med tourism:
it was privvy to the elite now its for middle to low incomes as well. The recovery rates are better, and the doc stats are transparent

med fraud:
docs are notorious for fraudelent claims/overbilling
http://www.mymedicalcontrol.com/

clinics:
companies setting up clinics in their stores are Wal-Mart, Target, Kroger, Walgreens, Eckerd, Duane Reade, several regional supermarket chains…
MinuteClinic, Take Care Health and RediClinic

credentialing:
http://www.ratemd.com

search engine/semantic web:
google health correct diagnosis about 58% of the time
this # will only improve…


Best of Luck Tina,
you are not alone !

That last inchoate jumble is not an argument for medical care as a right.

Ahh but Ch did you do that with a family of three to house and feed? How much is insurance for a middle class family of three? My self employed brother was quoted about 600-800 bucks a month.

After my son was removed from medicaid I tried a year of the worst insurance imaginable through the university system. ten months and seventeen claims to get one ER visit covered. I dropped the insurance and payed cash-50 bucks each visit.

I guess I didn’t contribute to the antibiotic overuse problem because my kid only went to the dr as a last resort. 50 bucks on 200 bucks a week salary is a quarter of my income. You should not have to face the choice of paying rent, feeding your children or providing them with medical care.

My sis saw a dr like yourself. Her daughter broke her leg, had the cast put on in the ER, was covered by medicaid. When it came time to remove the cast the dr refused as he didn’t accept medicaid. She had to pay about 250 before he would remove the cast. She called around to multiple other physicians trying to find someone and all said it was this physicians ethical responsibility to remove it. Three weeks past the original removal date she finally took her daughter to the children’s hospitol 60 miles away where they removed it. When her other daughter broke her arm she went to the same local hospitol, with the same on call physician. She had them put on a temporary cast and then left and drove to the children’s hospitol to avoid dealing with his greed again. This shouldn’t have to happen.

OK..the presumption is that 250 dollars is too much to pay for a cast to be removed.

then what is a fair price for a cast to be removed? how does one obtain a a fair price estimate?

Tina, you are pimping poverty as a way of avoiding the issues here, unless you think that one person’s “need” should imply the right to take the labors of another. Is that what you meant to say? All the other assumptions you make about the backgrounds of doctors–shoving silver spoons in their mouths–is really nothing more than cheap ad hominem, to wit: “you didn’t come up poor, so how can you have a valid opinion about how valuable medical services should be provided (even though you may be a provider.)”

I think the above is true. It is assummed that charges are “cash in the pocket” of the provider. This is not the case. After medicial school I owed 60,000 just to get the MD degree. During residency I could not save any money as the residency wages were barely hovering above poverty level for the state of Mass.

That is only a fraction of the costs that are needed to keep a practice going. I’m lucky that my malractice fees are under 15,000/year but my other office costs (nurses salaries, front office staff, licensce fees, educational fees,) would demand that over 50% of my income went to keep the practice open. So…yes…office charges are high.

oh yeah one other thing…I drive a beat up minivan that now has 122,000 miles on it.
I will keep it until it dies. Today the catalytic converter cover became loose.
It costs me 75 dollars just for the estimate
(not to even attempt a fix..which now I am told will be 900 dollars) Seems steep to me, but I have to have car to work. anyway the shop won’t have time to work on it until the next day. I would sure like to have the charges just cut magically in half, and I would even more like it to be fixed today. Having a affordable, immediate car care should be a right as well. ( as well as taxi trips that are under 15 dollars). One can easily argue that transportation is more important than health care.

NO, transportation (and healthcare) are not implicit rights…

A free market is an implicit right …
meaning consumers are able to find a diverse group of auto providers in a variety of price ranges, competing to the point that most give free estimates. there do exist turf wars between dealer providers and independents but the fact that a majority of bankruptcies in this country are not attributable to auto repair bills- lets most in US rest easy about any impending auto crisis.

the same is not true of health care… ie there does not exist free market in that industry, ie over half of bankruptcies are medical$ induced.

So again, neither are an implicit right… but equitable distribution, competition, anti-trust, free market -> these very much are.

have a nice day!

the immediate above statments are interesting , but please cite some accurate data to lend some credibility.

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