There seems to be a struggle in America among health care providers who work to prevent disease or cure it. Some focus on making the ill well. Other health care providers see their priority as the bottom line. The health care problem in America is serious. Yet, it has little to do with medical and scientific knowledge and discoveries. We are proud to find new medications, drugs for the average American. However, the problem is one of cost and expense. Some European nations provide general national health care. America is serviced by both for-profit as well as non-profit organizations. They vary in the types and even quality of service. Most importantly, they vary in the cost and fees they can (and do) charge their patients. What is perhaps most important to this discussion about difficult choices that so-called “good people” have to make is the cost of insurance. Even with insurance, the specter of expensive co-payments as well as denial of services by some insurers. “Pharmaceutical companies are making big bucks, U.S. doctors are some of the highest paid, fancy new technologies are being sold that purportedly do miraculous things, the hospitals are getting their cut and the insurance companies keep raising their costs, so surely all is swell. Not really. According to the N.Y Times there are ’60 million uninsured during a year (May 13)'” (Engler 2003 1)
All too often we read about court cases, even deaths to patients denied coverage by their insurers. Why? Because the treatment is regarded as “experimental”. We also see insurance companies anxious to move patients out of expensive rooms and back home as quickly as possible., This has led to some hospitals’ discharging a new mother. Maybe she just gave birth within the past 24 hours. Out she goes. It’s an HMO or hospital policy. Not that her bed is urgently needed. Rather, the insurer is trying to save additional hospitalization costs.
Politicians, especially Hilary Clinton, have sought to bring up the idea of a national health insurance bill. It has been defeated every time. Who opposes national; health insurance? A combination of HMO and pharmaceutical and insurance company lobbyists. Also, those concerned with the overall cost and its effect on the nation’s budget. Strangely enough, there seems to be argument when President Bush asks for $87 billion to rebuilt Iraq. Millions of children- and not all of them at the poverty level- are totally uninsured. Those billions could do more good at home here.
Kidder is correct when he writes “All of us face tough choices” (Kidder 1996 3). However, facing tough choices is not the same as having tough choices imposed on one. In the case of health care, it is not merely a choice of which doctor to see, or which surgeon to call on, or even which hospital to enter. It is a choice between illness and the ability to pay. It is
interesting to note that Kidder (16) claims that tough choices tend to pit one “right” value against another. This is hardly the case with America’s health care choices and resulting problems. Frankly, for many Americans, including much of the middle class, the tough choice is going into debt, or putting off treatment until one can afford it. On the other hand, the choice is going to a second-rate facility with a less experienced staff. Unlike the top-rated institutions, here everything is crowded. It is often a choice between cure and continuing illness, between life and death in some cases. Kidder (17) separates right-from-right choices with right-from-wrong. Cheating is wrong. Upholding a community’s moral standards without damaging freedom of expression is (according to the author “right”. Given this black and white approach, where does that put the senior citizen who buys his medications in Canada at more than 50% off American prices. Where does that put the cancer patient who heads to Mexico for what he believes is a miracle cure. Manufacturers, HMOs and even doctors do not support this. The fact is clear- when it comes to the health care crisis in America, we are seldom able to make clear choices, no matter how tough, because our ability to pay health care providers is so limited.
Let us look at Kidder’s four paradigms, dilemmas the author feels are common to most of us:
Truth versus loyalty. This means that someone entrusted with a secret, for example, yet wanting to be honest with a friend or co-worker, “could not choose both” (Kiddder 19). Kidder sees this as an ethical dilemma, a right versus right situation which, for the individual(s) concerned easily becomes a no-win situation. Within the health care crisis, this paradigm has a very chilling counterpart. Imagine the family doctor who receives a certain royalty, or fee, or kick-back, or commission, for referring his patients to a specific health care facility, or who is forced to deny a procedure knowing the insurer will not cover it. The moral dilemma here is clear-cut. Who comes first, the doctor’s income- and his stranding within the health care provider which gives him a majority of his income, or the patient? There is now even the question of time spent with each patient. Many doctors are literally forced to see a certain number of patients each day. That limits the patient’s exposure to the doctor. We now have a very unusual new “practice”: some doctors now charge an annual fee. It is not a low dollar amount, either. This fee gives their patients better entry to the doctor. The doctor now can spend more time. If you can pay the fee, you get the time. If you cannot, then you are forced into crowded doctors’ waiting rooms.
Individual versus community. Kidder (19) asks this question in his example of potential AIDS-contaminated blood transfusion: “What should he tell, and to whom should he tell it?” The moral dilemma is far worse when a doctor or health practitioner has top tell a patient he cannot be treated because he is uninsured. Or, he is sent to a second-rate institution where they “accept” uninsured patients. Here the moral dilemma is simple: How can a practicing doctor tell his patient he is too poor or too uninsured to get his help. Who is at fault? Not the doctor, working under a severe time and dollar handicap. It is the overall community- in this case the entire nation, which has caused this wide gulf between those receiving optimum care and those relegated to second-rate health care, if any care at all.
Short-term versus long-term. Kidder claims sometimes you cannot have it both ways- both a short-term settlement and a long-term favorable result. Yet, since this book was written some eight years ago, Kidder never goes into the health care problems. Perhaps he doesn’t (or didn’t) consider them tough choices. Kidder sees this paradigm, in terms of “now versusthen….difficulties arising when immediate needs or desires run counter to future goals or prospects” (Kidder 1996 113). Look at how the pharmaceutical companies distort and pervert this paradigm. They keep price4s high during the short term because, so they claim, the money is needed for research. But, as soon as their patents expire and generic versions appear in the market place, their prices drop sharply. There seems to be no doubt that prices could be lower, and the companies would still earn a profit and have money left over for research. Their pricing is short-term with a vengeance.
Justice versus mercy. This is a difficult dilemma when it comes to health care. The mercy is taking care of all the sick. Justice is, I guess, making a profit. The profit is so that the hospitals and doctors and insurance companies and pharmaceutical companies can stay in business. But, there is justice and there is JUSTICE. Why do some good people make the tough decisions to take a bus to Canada to save on the same drugs they get in America? Is that justice? Why do the rich get better treatment, and get it because they are willing to pay more? Why are inner city hospitals under-staffed? Why do African-Americans have a shorter life span than whites? Why don’t doctors and hospitals take care of the sick FIRST, then ask about insurance? Good people remain sick. Good people die earlier because they cannot afford insurance.
Kidder’s book is full of examples. But, they do not really deal with the health care crisis. His examples are ethical. They are moral dilemmas. They set truth against lies. They set honesty against pressure. Health care should not require us to make tough choices. Health care should make things easy. We should be GUARANTEED the best health care, regardless of how much we can pay. We should be able to buy medicine without having to go to Canada or Mexico. In other words, Kidder’s four paradigms are not truly applicable.
So, what would I suggest? To begin with, people need good information. Information about who provides the best health care. How to get insurance that one can afford. Even how to fight for your health care rights.
A reasonable solution to the health care problem has to have information. We don’t have it. “‘Is the quality of U.S. health care adequate? Is it getting better, worse, or stay’. We don’t really know.’ Drs. Mark Schuster, Elizabeth McGlynn, and Robert Brook, national experts on quality of care, observe that “More in formation is available on the quality of airlines, restaurants, cars, and VCRs than on the quality of health care.” (www.rand.org/publications/RB/RB4524)
Politicians all have an opinion. Here is what Carol Mosely Braun says: “If you think about it, every person in America can get health care, whether or not they can pay for it. The problem is that because of our inefficient system of payment, many, if not most, get the most expensive care, many more get inadequate or postponed care, and still more live in a state of anxiety about their ability to maintain their health. Emergency rooms are all the health care delivery system many people know, and insurance companies make decisions doctors used to make” (Braun 2003 1).
Politicians are looking for “themes”. Ws should be looking for answers. Health care is expensive and too exclusive in America.
Here is what I recommend:
1) Create a national health insurance program, paid for from income and sales taxes. 2% of all taxes go into a national health care fund. People who can AFFORD to pay, as they do now, will continue to pay. Those that cannot must show proof.
2) Give doctors and hospitals an incentive to treat ALL patients, regardless of private insurance or ability to pay.
3) Regulate profits and audit research expenses of ALL American pharmaceutical companies. Charge an excess profits tax.
4) Create national scholarships for young men and women willing to go into pediatric medicine.
This may be naïve. But, there seems to be no alternative now. We are the richest country in the world. But, when it comes to health care, we are not near the top (except in costs). The President and Congress now must make a tough choice. Do something now, or risk a health crisis which will make America look cheap and uncaring to the rest of the world. “By themselves, these paradigms won’t make those choices for us” (Kidder 1996 221). In other words, we need help from people, not words in books. Action, not paradigms.
Braun, C. M. “Statement on health care in America”
Engler, Y.: “Pay More To Die Earlier” Counterpunch, May 29, 2003 www.counterpunch.org/engler05292003.html
Kidder, R. M. How Good People Make Tough Choices A Fireside Book (Simon & Schuster 1996
No author listed: “Taking the pulse of health care in America” found on www.rand.org/publications/RB/RB4524