“It’s not your fault.”

The question of “economics versus morals” is the central debate between health care professionals (physicians, public health and health policy officials, etc.) and other educated people who don’t readily accept the principles and dogma espoused by the former. When Dr. Paul Farmer, the hero of international public health and the physician described in the book Mountains Beyond Mountains, came to speak for my “Global Health Challenges” class, he encapsulated the otherwise difficult to describe fervor of the health care community in a single word, a practice he felt that others should also subscribe to: mercy. My immediate, admittedly cynical (or you might say, realistic or logical), thought after he said that was, “Who’s going to believe that – that ‘mercy’ should compel them to care about people dying of readily curable or treatable diseases like AIDS, tuberculosis and malaria in developing countries? Who is going to pay for that, just out of the good of their own hearts?”

You first have to understand where I stand: whether or like it or not, I don’t find it difficult to understand most people, their motivations and their fears, their potential and their limitations. At this point in my life, I see my place as being on the line between two (or more) camps, trying to find ways to encourage cooperation and find solutions that benefit all parties – something that some people tend to believe is not possible (in a capitalism-styled world where one man’s loss is another man’s gain, where everything comes at a price). As such, I believe in the power of mercy – that mercy is perhaps the one human quality (more so than intelligence) that makes us truly human and “higher” than other forms of life. Unlike most other forms of life, our early ancestors took the bold step of caring for their sick, realizing that they could find strength in community and in the investment of relationships tested by the threat of death.

I am making no assumptions about the “good” of human nature: I believe in a full spectrum of possible behaviors and qualities of character that individuals are capable of attaining. As such, I believe that the question of “right” or “wrong” is often framed too simply and too feebly to either convince the opposition or generate a compelling, effective solution that overwhelms the opposition’s will (especially if it is reluctance to do something, such as pay). Countless historical examples have proven this: that people in general are not so much interested in what is moral, but rather, what will bring them the most gains or the least losses in more material or tangible realms. Accordingly, when health care champions cry out, “Help these people!”, I can empathize with those who say, “Why should I?”, even if they are capable of doing so. Being a first generation immigrant and having gone through the long and tedious process of naturalization, I do hear a voice in my ear (often with the texture and tone of my father) saying “Why should I spend my hard-earned money on someone else who isn’t me or my family?”

At the heart of this sentiment are a number of core beliefs. First, that community is a limited concept: most people care about other people, but the number of people they care about and the extent to which they would help those other people varies greatly. Many people would only care and take care of their family (which is reinforced by cultural traditions of familial obligation and the need for a constant support structure), sometimes friends and neighbors (who may serve as surrogate family structures), occasionally local community organizations (like schools and churches), and in proportionally few cases, distant beneficiaries (those who benefit from charities). This, to most people, sounds reasonable.

The second assumption, however, is more troubling. This assumption is that if you get sick, it’s your fault. This is refuted by the assumption that we, as mortal beings, are subject to random chance or fate. Science has not provided any emotionally or psychologically satisfying explanations for why random chance exists: it is a fundamental principle of the universe. As such, this assumption of fault is reinforced by two branches of thought.

1) There is the religious belief: that if something bad happens to you, it’s because it’s either a test of your soul or it’s punishment for sin or wrongdoing. This reasoning is more convincing for those who suffer, because it gives meaning to the suffering. When you’re in pain, you need to feel that it was for a reason, that things will eventually get better. Otherwise, there’s nothing left to live for.

2) A more superficial reason that is still quite deeply embedded in our psyche is that people get sick because they don’t take care of themselves. In a split second, the judgment is made: that it is your fault, to whatever degree. This is perhaps the principal reason why people are so concerned about patient privacy and so obsessed with not talking to other people about their medical problems: most people fear the stigma and the blame involved in being sick. The easiest example to see this is with asthmatics: patients are expected to manage their own care, and if they have an asthma attack and are rushed to the emergency room, they’re berated and told, “You should have come in earlier” or it is assumed that they did something wrong.

This is the main, erroneous assumption governing the health care delivery and payment – this is the straw that breaks the camel’s back. By corollary, many people believe erroneously that all diseases and disabilities can be prevented. And it all boils down to money: what happens to those who are too poor to take care of themselves? And this isn’t a black or white picture of whether or not people can take care of themselves: it’s a spectrum where the richer you are, the better your chances of living a longer, healthier life. So much of the morbidity (i.e. state of being sick) and disability experienced by the majority of the world’s population could be addressed and/or eliminated by amounts of money that are currently available – if only the people with the money were willing to spend it. Even with the Gates Foundation, the Howard Hughes Foundation, various national governments, and other charities and NGOs, there is considerably debate as to where to allocate the resources that are available. How many cases of malaria could be prevented if every person in Africa were provided with an insecticide-treated bednet and taught how to properly use it? If there were more leaders and champions like Dr. Paul Farmer with the ability to mobilize and acquire the human and financial resources required to battle an infectious disease that still remains a death sentence in developing countries (unlike in the U.S., where it is manageable), how many more cases of HIV/AIDS could be treated and how many more years would those patients have to live and contribute to their communities?

Here in the U.S., in varying degrees, people are quietly ousted from insurance coverage because they can’t afford enough of coverage for their health needs or they can’t afford it at all. Insurance plans become exponentially more expensive (or cover less) when you have more health problems, particularly if you have to start a new plan with a preexisting condition. I like using asthma as an example because it is a disease that troubles a vast population of patients (hundreds of millions) and isn’t a compelling case where other people might say, “You have this because you did something stupid.” Someone I know, a middle-aged physician with severe asthma, declined one job offer where the employer’s health insurance plan offered him only $75,000 of coverage per year because of his asthma (compare this to my standard-issue health plan which offers $1,000,000 over my lifetime if I stay with this provider, most of which would likely be spent after age 50). If you think about it, $75,000 isn’t that much money given the behind-the-scenes pricing of in-patient facility visits, tests, medications, procedures, surgeries, etc. Those who can’t afford the insurance take advantage of the one loophole – the one tangible instance where the government has stepped in to try and alleviate the problem – by going to emergency rooms for non-urgent care, where they are always guaranteed (by law) a medical examination. This, in turn, is breaking the system of emergency care: according to one Emergency Medicine department chair I heard speak recently, almost exactly half of all ER cases around the U.S. are for non-urgent health issues. Accordingly, all admissions to the ER have to wait longer for care, including those wealthy people who could consider contributing financially to the health care of others but decided that they didn’t care.

Erroneous Assumptions

1. “The United States has the finest health care system in the world.” – This statement, if not properly articulated with further support, is just plain wrong. Among the most wealthiest, developed/industrialized countries, the United States ranks near the bottom with respect to life expectancy. Furthermore, the U.S. by far spends more money than any other nation on health care. The U.S. has one of the least efficient (dollars spent for years of life gained) health care systems.

However, the U.S. health care system is unique and has an advantage over those of other nations: the internal culture of the medical community and the reciprocal demands of the American populace (i.e. the patient population) drive towards aggressive care. In other (vernacular) words, American medicine is hardcore. While it may be easier to gain access to (possibly better) primary care in other developed nations (like Canada or the United Kingdom), there’s no place you would want to be to get medical care when you are really, really sick. In this sense, these nations do a much better job of practicing preventive medicine for most of their populace, while the U.S. does a very good job in some respects and a terrible job in other respects. For example, I will soon be working in a clinic for men who are trying to kick the habit of drug use. One of the main services that we (as medical students) can provide is TB (tuberculosis, also known as “consumption” to those familiar with Victorian literature) testing. Who gets TB these days? I would bet that many Americans think “people in third world countries.” Yet I’m talking about people in America. Americans.

2. “The advent of insurance has kept it so that the actual out-of-pocket expenses per person as a percentage of income have not changed all that much.” – This assumption misses a key aspect of disease and its effect on people’s lives: that people who don’t have much money may be more willing to deal with more pain and suffering because they can’t afford to pay for more health care out-of-pocket. It’s all in the word “adequate” – what is adequate care? To those who have “enough” money, adequate care means acquiring the best treatment available to eliminate or manage disease according to the best possible outcomes (previously reported). For those who don’t have as much money, they have to perform triage with a prohibitive amount of financial resources: what’s more important, paying the rent or paying for your kid’s surgery to correct a congenital heart defect? Foregoing a car and riding the bus to work or dishing out money to pay for a HEPA filter and allergen-free bedding for your mother who has asthma? The blind, ignorant cruelty in the assumption that illness is the fault of those who are sick is that these measures that people with less financial means choose not to pay for (because they don’t have the luxury of paying for them) are typically preventitive measures that would likely improve their health conditions and reduce their morbidity and disability. Sure, these measures are likely to help, but many people can’t afford to pay for it when they have other life essentials to pay for: food, housing, transportation, family support, education, etc. How can you blame them?

3. “The market system efficiently allocates resources and talent to maximize productivity and efficiently matches patient’s desires with willing and able health care providers.” – Don’t make me laugh. Again, it’s a matter of how much money you have: if you have the money to pay for efficiency, then you can get efficiency. If you’re like most people, then you’ll have to deal with the inefficiency that is characteristic of the American health care system: long waiting room times, minimal time spent with a doctor, barriers to emergency care (i.e. delays due to sorting of patients by urgency of cases in the ER), inconsistencies in insurance coverage and payment practice, etc. If you don’t know what I’m talking about, chances are you’ve lived a very privileged life and haven’t seen what life is really like for most people. This is not to say that the market system isn’t the best available option, but it certainly is not a model of efficiency.

Concluding Thoughts

1. Preventine medicine cannot prevent all incidence of disease and disability. Preventive medicine is not the final answer – alone. As valuable as preventive medicine can be in reducing the incidence and severity of disease, it cannot be a lone solution to the problems of the U.S. health care system. Disease and disability will always happen because of random chance. Furthermore, correcting the inability of a stratified, capitalist society to provide proper preventive care for everyone (”proper”, meaning care that would ensure that each member of the populace would have an equally small chance of becoming sick to the given level of severity) is a challenge that may not be surmountable without prior changes in the health care system and in the societal and cultural fabric of America. While it’s a worthy goal to spread preventive medicine and primary care coverage to all sectors of the population, everyone needs to understand this will not solve all medical problems. However, it can substantially reduce unnecessary suffering and improve health on a population scale. Yes, we need to address problems in American primary care and expand health insurance coverage. But first, the idea that “it’s your fault that you’re sick” needs to die, right now, because otherwise, we’re digging out own graves: it only increases the health disparities along economic lines, and once that random chance chooses you to be sick, you will rapidly fall down a slippery slope to impoverishment as your insurance provider quickly ousts you from coverage as you become progressively sicker.

2. It’s not useful to think of health care strictly as a right or as a commodity. It’s both. A “right” is something that we want to believe everyone should have. According to the U.S. Constitution, we want everyone to have certain freedoms and liberties, and even more extremely, we want everyone to have the ability to freely pursue happiness. Arguably, one cannot adequately pursue happiness with disability and disease in tow. A “commodity” is something that we believe people should be responsible to pay for if they want it. As of yet, medical care isn’t being distributed to everyone for free, and it doesn’t seem as though it will be universally anytime soon.

Though it may seem like an odd statement, even those rights we consider most pure and fundamental are commodities that we pay for. After all, we pay federal taxes to a government that “protects” our rights. If we don’t pay taxes, we’re audited and possibly thown in jail (i.e. deprived of those rights). Immigrants often “pay a price” (i.e. abandoning their jobs and social status and starting out at a lower rung in America) to come to the U.S. for political freedom to escape oppressive regimes in their home countries. Similarly, the argument that health care is a right follows the same line of reasoning: if you don’t pay for it, you don’t get it.

Except, in America, you do – a little. As I mentioned before, you can still go to the emergency room and at least be guaranteed a medical exam, if not treatment. If you are in bad enough shape, then the physicians and nurses will try to treat you and often the city or the state government picks up the bill. This is a broken system, and it’s getting worse.

3. Who should pay for it? Everyone. – Everyone should have some part in paying for their own health care, provided that they can afford it in the first place (i.e. not people who are covered by Medicare and Medicaid). Unfortunately, our lack of creativity so far suggests that the only way we can do this is with government regulation (whether on the city, state, or federal level) since market forces aren’t going to ensure that everyone gets care (back before the government intervened in ER care, patients were turned away from ERs if they couldn’t pay). There may be another solution that has yet to present itself, but I’m currently of the mind that insurance-covered primary care should be provided to all American citizens (and hopefully, to resident aliens and immigrant workers) in a bracketed system so that people with more financial means pay more and those with less means pay less. As for who pays for tertiary care (i.e. when you’re really sick), I’m not yet certain: right now, it’s typically either the government through Medicare/Medicaid or insurance companies, but insurance companies are increasingly showing resistance to paying for the care of their clients when they are very sick (claiming instead that the clients were negligent in the management of their own care or were taking risks with their health). I do think that this question of “who pays for it?” is a vital question, but the question needs to be asked in the right context and with the right background knowledge.

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