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Universal Health Insurance Coverage
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
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), 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.
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.
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 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.
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.
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.
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