Tuesday, July 1, 2008

Health Care: Rights and Responsibilities, Part I

At the heart of the current debate about health care is a fundamental, although oft-overlooked central question. Each person must answer this question carefully, because there are ramifications involved in the choice, many of which are unpleasant. The question simply put, is this:

"Is health care a right?"

In order to fully contemplate this question and formulate an individual answer, we must first examine it, dissect it, and try to truly understand what it is, exactly, that we are asserting with our answer. There are two main terms in this question, namely "health care" and "right", and we will examine them in turn.

Health care is a bit of a loaded term. It is subject to variation in definition depending on the age, race, geographical origin, language, and even life experience of its user. With such a wide range of interpretations, it is daunting to attempt to assign a value to this commodity which has been increasingly regarded as something to which all should have equal and unquestioned access. And it is this exact obscurity that fuels the continued debate about what that free access would mean, both to the recipient and to the person or people who are made responsible for the provision of that service.

There is an inherent "slippery slope" element to the definition of universal health care. Even nations with the longest history of mandating this service continue to grapple with the issue of what, exactly, constitutes the "health care" to which they assert their citizens have a "right". For example, most universal health care proponents would argue that routine obstetric care should be provided. What is less clear is whether there is an equal right to elective pregnancy termination. Similarly, although one of the commonly claimed benefits to society stemming from the provision of universal health care is the reduction in cost to society that is gained by providing previously inaccessible preventive care to the people, thereby reducing expensive management of chronic diseases. But what is society willing to do to those who knowingly reject this preventive care and opt instead through action or inaction to get what would have been a preventable disease? Will that person be removed from the rolls of the covered? That seems incredibly unlikely.

Boiled down, the basic principle behind the desire for universal health care by those who support it for the right reasons, is a genuine altruistic desire to create equity in a system that is used by so many. The unfortunate reality is that providing any need-based service is inherently inequitable. Those that use more of the services are always going to gain more, and pay less. Those that benefit the system most, by working hard, doing well for themselves, paying a much higher tax-rate, making good decisions, and taking care of themselves, will pay more and benefit less. Even among the utilizers of the system there is inequity. One need look no further than the current Medicaid system to see that there are those that overuse, even abuse the system to the detriment of both the system and to those who are more responsible users. Partial solutions to these problems have already been tried to very limited success. In Alabama, for example, in a failed attempt to save the cash-strapped system, a system of limits on numbers of visits and types and amounts of medications were put in place. This had several consequences, none of which had the desired effect. First, there were those for whom the restrictions on the numbers of medications had dire effects. It is not at all uncommon, as any family doctor or internist will tell you, for a patient to require many medications to regulate their numerous chronic health problems. The poor medical control of chronic health conditions that resulted, contributed to by the limit on the number of covered visits, caused the system to fail to do its most basic jobs - provide adequate care and reduce the cost to society from untreated patients. It is a devil's game - pay until there is no more money and nobody gets care or reduce what you will pay for and only a few get care in a system that could accurately be described as unfair.

To be sure, there are also those who support universal health care for wrong reasons. There are those who would love to be the gatekeepers between the citizens and something they need as desperately as they need health care. Only the power to regulate food and the ability to regulate energy would be greater powers, and there are some who are suggesting that too.

But what of this notion of health care as a right? What exactly constitutes a right? Who gives these rights? Should health care be considered a right?

A person, we would all agree, has a right to walk, unmolested, down a street. His right is protected by the Law, but there is no guarantee that he will, in fact, be able to make it down the street. If another person hits him with a rock, then that person has violated his rights. He is breaking the Law, along with the first man's skull. The Law may punish the second man for violating the first man's rights, but the Law can do nothing to unhit the first man, or to make it never have happened. That one is easy, but is also silly. It does demonstrate an important point, however. Whether you believe that we derive our rights from a Creator, as the founders did, or from some Universal Source otherwise undefined, or from our historical, evolutionary ability to live together in groups, the bottom line is the same. There are rights, but there are no guarantees. I have what I believe is a God-given right to live unmolested by others, work for my livelihood, start a family, raise my children, and enjoy the fruits of my labors. I have absolutely no guarantee, however, that those things will definitely happen. God, or the Universe, or evolution, or bad decisions, or plain old bad luck may prevent me or not allow me to have those things I listed. I may not be attractive to the women I like, and may stay single. Surely the need to procreate and continue our species is in the same category of importance as the need to be healthy. Strangely, however, the government has not yet promised Universal Relationships in the same way they've promised Universal Healthcare. Is not procreation a right? What about couples that remain childless, despite their best efforts? This is a devastating situation. Don't they have a right to produce children? Perhaps their fertility treatments should be fully funded as well? If not, then why not?

My point is simply this. We have a right to "pursue happiness", not a right of guaranteed happiness. Similarly, we all hope and pray that we have good health. But this good health is not a guarantee. It is a blessing, or a stroke of good luck, or good karma, or whatever you believe. It is no more government's to give than it should be theirs to take away.

What of the people who provide this health care if it is a right? If access to health care is to be guaranteed, how is it to be guaranteed? What if the health care providers refuse to work under the new circumstances? It is already clear how the government responds to the physicians that provide their services to the currently governmentally-insured. Medicare reimbursements continue to drop at the same time that costs are going up. Many physicians are opting out of Medicare for this reason. So what if the same happens on a larger scale under the Socialized System? It seems to me that if that guarantee is to be made, there are only two options for the guarantor.

They can agree to pay more under duress, in which case they are at the mercy of the health care providers. This exact problem in other countries has caused many of the governments with Universal Health care plans to literally outlaw the practice of medicine outside the government system. This is horrifying to me. Just think about what this means. The people who have made a conscious decision to seek health care they pay for themselves are prevented from doing so by the government. In this sense, the government, rather than being the vehicle by which the people are able to exercise their rights in safety, becomes a literal obstacle to the free exercise of the right to buy something you want to buy. And all because they want to be, they must be the only provider of the health care "right" if the Socialized System is to succeed.

The other option for a government faced with physician resistance is to force compliance. Once health care is promised, it must be delivered. If physicians are not willing to work for little or nothing, then perhaps they must be forced to. Compulsory service was outlawed in this country centuries ago. I pray that we are not heading down that road. Many would love to see a world in which the people who are perceived to be "rich" are brought low - made to suffer. But think about that for a moment. How many generations of gifted doctors do you think it would take for those with gifts in the medical field to choose not to enter a field in which there was a real possibility that they might be disenfranchised, or even forced to work for no profit? Those people would choose other, less dangerous work. I really can't imagine what sort of person would be attracted to a job where there was no chance of making a living. But somehow we expect this of these "physicians of the future".

For my own part, I feel that health care, like health itself, is not a right, but is instead a blessing, and one's own responsibility. I say this, fully realizing that this, too, carries with it some problems.