We were exposed to mountains of rhetoric on health care reform during the past two years. The dilemma has been surfacing routinely in election years for as long as I can remember, and I have been involved in health care for more than 30 years. Is access to healthcare an entitlement–one of our inalienable rights–or is it a responsibility? In my experience, the arguments are more often emotional rather than rational. It seems much easier to fix the blame than it is to fix the problem.
Now, we have the most sweeping reform of the health care system since the creation of Medicare. Will it fulfill the promises that were made to gain the support necessary for passage? Will it really deliver affordable health care to more than 30 million Americans that were previously uninsured and reduce the escalating costs of health care at the same time?
During the last 30 years of my life, the cost of health care has continued to escalate at an alarming rate, taking an increasingly larger share of the gross domestic product of this country. The health care sector has become one of the largest consumers of our financial resources. Yet, today a growing portion of our population still cannot afford health care insurance. We must ask, “Why?”
Society of victims
At the risk of sounding callous, I believe the crux of the dilemma is the lack of accountability. I believe we have become a society of victims. “Whatever my current problem, it is not the result of anything I might have done, but it is the other guy’s fault.” A physician friend who served in the emergency room of a major metropolitan hospital related a chilling story that illustrates my point. A colleague had pulled duty in the ER every day for a week and thought it was strange that the same woman was sitting in the ER waiting area every day. Finally, his curiosity got the best of him and he went to her and asked what was wrong and why she was there. To his inquiry she reportedly replied, “I come here every day because one day one of you will make a mistake with me, and I will be rich.”
Whether the story is true or not is less the issue than the possibility that in this day and age it might be true. Many health care professionals have related stories to me regarding the expensive diagnostic tests they feel obligated to employ as part of their regimen in the event that they may be sued for malpractice. Furthermore, malpractice insurance, which has become a necessity for most care providers, sometimes exacerbates the problem because the insurance company will determine that the legal cost of defending the client may actually be more costly than agreeing to settle out of court. Do you suppose this fact has escaped those whose careers are built on this type of litigation? Is that why tort reform was noticeably missing from the new health reform law?
A new perspective
In my opinion, the solution to the problem of the rising cost of health care, coupled with the lack of health insurance protection, requires a new perspective on accountability. If you wish to benefit from some form of health insurance (be it Medicare, Medicaid, or a private insurer), you should enter into a contract with the benefit provider through which you include a set of advanced directives, drawn up with your input and from your family and legal advisors based on what you want as your end-of-life decision. This contract would be binding on you and your heirs and would help the insurance provider calculate the risk and the resultant premium necessary for them to provide the health benefit you required.
In short, you would be ultimately responsible for the amount and quality of care you wanted to have delivered to you and would have made the cessation of life support decisions in advance. Whether the contract was with an insurer or CMS, you would have made a decision and accepted accountability for the health and life decisions from that point forward. Then providers would be obligated to follow your directives. These decisions would also bind your heirs; if they were to file any legal action against the providers and/or the insurer in violation of this contract, all monies paid as health benefits by the insurer would be due and payable by the estate and heirs of the insured. I believe this strategy would preclude the large number of legal cases taken on contingency by those lawyers who anticipate an out-of-court settlement, since the suing party would be at risk for the benefits received to date. This strategy might also provide the proper platform for building a portable health benefits plan, as long as the advance directives do not change because they would be the variables that would alter the original risk pool for the beneficiary.
I’m certain that legal experts will find flaws in this concept, and since I am not qualified in that area, I make no claims for the thoroughness of the legal arguments. However, if each of us is unwilling to accept accountability for our health and end-of life decisions, then we will be doomed to hear the same rhetoric from now until someone else makes the end-of-life decision for us.
The comment by the ER physician is accurate: While living in MD, we had lunch with a pregnant co-worker of my wife who said she was taking notes on every visit or medication she was advised by her ob-gyn, and if her baby didn’t turn out perfect or had any defects appear later in childhood, she was using the notes as a basis for suing the physician.
I also served on a jury in MD where a physician was being sued by a mother who delivered a down-syndrome baby. She claimed she did not understand some test results, and therefore the doctor was being sued for the full life care expenses of the child. We jurors ruled in favor of the doctor, but an alternative juror (who fortunately didn’t get to vote) wanted us to “give something to the child” and was ready to vote in favor of the plaintiff – here’s a summary from the local news: http://articles.baltimoresun.com/1997-10-22/news/1997295049_1_down-syndrome-children-minsky-elliott