The healthcare debate--is it misguided?

In the aftermath of the tragic shootings and deaths involving my congressperson and a number of her innocent constituents at my local supermarket in Tucson, Arizona, there has been a call from both ends of the political spectrum for a more civil discourse in the political arena. In no area is this more needed than the ongoing debate over the provision of healthcare in this country. In 2009, the economic cost of healthcare was 17.6% of our country's gross national product, and is estimated to increase to 19.3% by 2019.1 Yet, despite the technological sophistication of healthcare tools potentially available to Americans and the enormous amount of resources spent for healthcare, by many benchmarks, the health of most of Americans lags behind those living in countries where per capita healthcare expenditures are much less.2 According to the World Health Organization, the United States ranks a paltry 37th in health care system performance with similar statistics for infant mortality and life expectancy.3 Furthermore, readily accessible and affordable healthcare is not available to 16.7% of Americans who have no healthcare insurance.4 Thus, it would appear that the problem with the American healthcare system consists of two major issues. The first centers on whether the current expenditures on healthcare are being appropriately apportioned. In other words, are we getting the best “bang” for our “buck”? The second is how to address the issue of accessibility. It is my contention that we as a nation must come to consensus regarding the second of these two issues before we address the first. The current debate over healthcare has focused on the The Patient Protection and Affordable Care Act, often referred to as “Obamacare” by its opponents. Adjectives applied to the act have varied from “job killing” and “unaffordable” to “historic” depending on whether the writer or speaker is an opponent or a proponent of the measure. However, I believe that the focus of the debate is currently misdirected. We, as Americans, need to develop a consensus as to whether healthcare is a “right” of residency in this country. In the Declaration of Independence, our forefathers wrote “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”5 Subsequently, in the preamble to the United States Constitution, it was written “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare…”6 Does either of these statements or the documents themselves imply or guarantee the right to healthcare? For many Americans, this is “settled case law,” but this was not always so. Before the advent of health insurance in the United States, accessibility to healthcare was determined by the ability to pay, availability of some “public clinics/hospitals” or the benevolence of charity. This was not necessarily a public policy issue because the cost of medical care was relatively inexpensive. The cost had some correspondence to the benefit of care because in the early years of our country, medical “science,” and hence the practice of medicine was not necessarily beneficial, and in many cases was detrimental to health. However, with medical advancements in the 20th century, there clearly was a benefit to care from a physician along which paralleled an increase in medical cost. This eventually led to the initiation of employer-sponsored and private health insurance, Medicare, and finally Medicaid. Concomitantly, there was the increasing opinion among the citizenry and policymakers that everyone is entitled to healthcare. Given the current turmoil over healthcare in this country, it is time to conduct a very civil discourse to reaffirm this belief. Because if we as a country decide healthcare is not a right, this entire current debate over healthcare is moot. We should repeal not only this current law, but also Medicare, Medicaid, and every other government sponsored healthcare program. Provision of healthcare again would be determined by ability to pay and the benevolence of any charity. If, however, we decide healthcare is a “right,” then the discussion should focus on mechanisms to deliver some basic level of universal healthcare to everyone in this country. The current law while mandating that everyone must have health insurance still does not guarantee this will occur although it is likely that there will be fewer that are completely uninsured. However, despite the protestations of opponents to the new law that no one should be forced to purchase health insurance, no alternatives have been proposed by its opponents to guarantee universal coverage. Some will argue that the country cannot afford the highest levels of healthcare for everyone. I would agree, and there needs to be a parallel non-histrionic discussion concerning the basic level of health coverage that all citizens are entitled. This should be a very public discourse, and not done arbitrarily by a single individual such as the decision by the governor of my state to deny organ transplantation coverage to Medicaid patients.7 We, as physicians, need to be front and center in these discussions over the provision and delivery of healthcare because as the vehicle for delivery of healthcare, we are in the best position to describe the impact of any proposal on the care of individual patients. If we do not take an advocacy position, policymakers may make decisions which will adversely affect our ability to deliver the best care for our patients.