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Universal Health Insurance Coverage
Rick Garlikov

There are some issues about health insurance reform that need to be kept separate in order to make the solutions more reasonable.

Speaking ONLY about availability of health care:
Money alone in the form of universal health insurance will not give everyone access to quality medical care because there aren't enough physicians.  And one of the raps on "socialized medicine" is that it rations care or cuts back on the quality care people have now.  But that is because there are not enough physicians.  And that is a problem we face under the current health care system, though it is not normally recognized as such.

 Universal health insurance is misnamed, and thereby gives the illusion of wanting to provide what is impossible to provide, or to provide with good quality – medical treatment for all who need it.  The concern that there are not enough good doctors is a real issue that would be great to solve if it can be solved, but that is not what "universal health insurance" is really about.  What it is really about is providing equal access to quality medical care for everyone so that no one is denied (at least basic -- however that might be defined) medical treatment solely because of inability to pay.

 All that will be changed in at least the short term even with an ideal universal health insurance program is who is able to see a physician.  Insofar as the system currently is operating at full capacity (which is often, but not necessarily always, true[1]), there will be no change in the ratio of people needing treatment to people receiving it, but now some mechanism other than money will have to be found to determine who gets (good) care and who doesn't.  If it means some form of rationing health care (by triage, "life boat ethics", or by "first come, first serve" up to the limit determined by each physician or department/unit/hospital of being able to provide quality service) that will be nothing new because health care is rationed now -- by income and/or insurance; it just means the mechanism or principles for determining rationing will now have to be different.  And while the old model of rationing by economics perhaps seemed "natural", in reality it was just as much a man-made system as any, and it was just as artificially discriminatory as any other system.  If we have the power to change it, then not changing it is a choice just as choosing any other form of rationing is.

 Under the current system, physicians don't have to turn away as many patients as they will under universal health insurance, but that is only because poor, uninsured people don't now call since they know they can't afford to be seen.  When affordability is not a problem, they will call, and thus some sick people will have to be turned away because there won't be time or energy for all of them to be seen.  But physicians should be able to come up with ways to handle that, just as they do now where the most popular physicians simply have full schedules and calendars and have to turn away callers because there is no timely time to see some patients.

 So the issue about universalizing health care access is only one of fairness of access, not of changing anything else.  And the issue it involves is simply how it will be paid for and where (or from whom) the money will come.  This is a moral and financial issue, however, not a medical one.

 There are two related moral issues, however.  1) Those with health care insurance now who are able to receive quality medical care may find themselves unable to get the medical care of their choice because those now excluded on the basis of cost will be taking up the resources previously available to those and only those who had insurance coverage.  That means for those with coverage now to politically accept universal health coverage, they will have to choose overall fairness over their own self-interest.  That is a difficult option for many people to choose.  The only mitigating factor is that though people with coverage now are in a privileged position, there is always the chance they could lose their coverage under the current system, and accepting universal health insurance would thus be a precautionary form of “insurance” against loss of insurance by, say, losing their job or having their current coverage canceled for any other reason. 

 2) There is also the moral issue of those who work to earn a living having to subsidize medical care for those who are indolent and who do not have health coverage because they do not choose to work.  Ideally, but not realistically, the indolent could be separated from the working poor, but if not, then a choice has to be made whether it is better or not to help the working poor (and those without work through no fault of their own) even if that means helping those who do not deserve it.

 A problem related to this second moral issue is the notion that what we all earn financially is a measure of the contribution we make to society, and thus, those adults who can afford health care now are those and only those who deserve it.  Without going into the details here though, I think that it should be pretty obvious that there are many people who work hard at jobs we all need done for pay that is much lower than the value of what they produce and contribute.  There are flaws in our economic system that not only permit, but that also perpetuate that’s happening.  Insofar as there are then the “working poor” or those who desire but cannot find reasonable and fair employment, it is simply not true that those with money are the only ones who make a valuable contribution to society.  Moreover, there are clearly many people who make far more money in a relatively free market economic system than they deserve on any rational measure of the contribution they make to society.  So I think the view that those with money are those who deserve medical care based on their contribution to society is simply false, at least in many cases.

 Conflating Other Issues with Insurance Coverage

Insofar as “insurance” mechanisms are employed that effect the practice of medicine -- those are different issues and need to be addressed as such.  E.g., all the “managed care” issues or what gets paid for and what doesn't, and all those kinds of things are separate issues from the issue of whether income and insurance should determine who gets equal access to care and who doesn't.  Likewise tort reform and malpractice reform, etc. (I  believe malpractice should be a criminal matter, not a civil one, and should have to rise to the level of criminal negligence or reckless disregard for human life to be prosecutable) and that any medical mistake or random occurrence (such as unforeseeable allergic reaction) should be treated as any other accident, where treatment falls under the health care coverage, though perhaps is expedited in some way.  Also, increases in quality medical education to produce more physicians, or  incentives to keep physicians in important roles rather than Hollywood plastic surgery, etc. is another issue, as is the institution of wellness payments as opposed to treatment or testing payments, etc.
It is important, I think, to keep these and other such issues separated in theory, even if they might turn out to end up being inextricably related to each other, so that they are addressed most reasonably in practice.

As to "managed care" -- my view is to let physicians know the total resources they will likely have available and let them decide how to distribute it based on patient need and likely outcomes, etc. Possibly with some sort of review process, but I see no reason patient care should be managed by insurance companies who can override the doctors.  Patients should then just go to insurance companies for their medical care if that is the way the system works, because the physician is otherwise irrelevant.

I want to propose the following as part of a solution to medical treatment rationing that is fairer than simply providing treatment for those who can afford it.  It is a limited resource health care delivery (i.e., "rationing") system model, which is based in part, and insofar as is possible, on ethical considerations of both desert and utility.  It is pretty commonly known that much adult illness and injury is at least partially self-inflicted through contributory negligence, and that a wellness model of public and private health care would cut down on the need for medical services based on sickness and injury.

 The model I am proposing is to determine who gets service, when not all can be treated, based on who is "medically innocent" versus who contributed voluntarily to their own condition -- when this is known, of course, which is not all cases.  And, of course, there will be some ethical problems with it that need to be resolved when this model conflicts with other ethically relevant characteristics.  But if, say, an emergency room can only treat four of five people that need their service and police bring in a drunk driver who caused the accident along with four members of a family in the car he hit when he went through a red light, then the drunk driver should be the one who is served last and all have life-threatening injuries that can be saved. 

 If a known choice has to be made between providing care for someone whose conditions is caused or exacerbated by their poor, medically relevant lifestyle choices versus someone whose condition is not in any way self-imposed, then all other things being relatively equal, I think it reasonable to treat the latter person if only one can be treated -- particularly if there are no other ethical features that conflict with this.

 Such a model would not only ration care in place of the economic rationing plan we have been using, but it would be an additional incentive[2] for people to follow wellness programs and make better lifestyle choices, thus improving the ratio of available health care to the number of sick or injured people.  Thus it is utilitarian in nature in its intent to foster greater health in the first place, while giving limited treatment resources first to those who medically deserve it by not having contributed self-inflicted harm. 

 However, it is important to distinguish lifestyle choices of the above sort from pre-existing conditions or genetic predispositions to illness, which are no one’s fault, and which could happen to anyone.[3]  Moreover, employment choices should not necessarily count as the kind of lifestyle choices to which I am referring. Soldiers or coal miners or others with jobs we all need done but that include more health risks than the average career should not be morally considered the same sort of lifestyle choice as choosing to overeat, eat poorly, under-exercise, smoke, or drive drunk.  The kind of distinction I am talking about should perhaps be based on some sense of “necessary” versus “unnecessary” risk, or worthwhile versus not worthwhile risk, or socially valuable versus socially detrimental or pointless risk.  But the notion of contributory negligence to one’s own health problems is an important moral concept which should not be defined arbitrarily or lightly if it is going to be a part of health care rationing as I propose, should rationing other than by financial resources be necessary.

This work is available here free, so that those who cannot afford it can still have access to it, and so that no one has to pay before they read something that might not be what they really are seeking.  But if you find it meaningful and helpful and would like to contribute whatever easily affordable amount you feel it is worth, please do do.  I will appreciate it. The button to the right will take you to PayPal where you can make any size donation (of 25 cents or more) you wish, using either your PayPal account or a credit card without a PayPal account.

[1] Sometimes there are, for example empty hospital rooms or beds in some hospitals, which might be filled if people who needed them could pay for them.  Ideal universal health insurance would make health care available to those who now need them but cannot pay for them.  But insofar as any hospital is at full capacity with patients under the current system, universal health insurance will not help those for whom no rooms are available.  Over time perhaps universal health insurance, if sufficiently funded, would foster more hospital rooms and more health care providers than are currently available, but the short term effect of simply adding money to the system will not increase capacity.

[2] An immediate financial incentive is sometimes more effective than is the incentive to avoid future illness for some people.  For some people, a higher probability of remaining healthy longer is insufficient incentive to make health lifestyle choices; and for some of those people, a financial incentive to make those choices will succeed where mere prudence fails.

[3] Financial protection for harms that could befall anyone through no culpable fault of their own is the very point of the concept of insurance in the first place.