Finally, as for we the patients, a realignment of our thought processes and a “slap upside the head” is in order. We need to acquire a sober, level-headed way of dealing with what can and can’t be done, medically-speaking. We’re all dying; it’s a matter of when and how.

First, a government-enforced individual mandate for a basic level of insurance coverage is needed. This is described in detail here. As Drs. Linda Blumberg and John Holahan aptly state, “Insurance pools cannot be stable over time, nor can insurers remain financially viable, if people enroll only when their costs are expected to be high.”

The next piece of workable reform is certain to be decried. It involves the acceptance that grandma and grandpa won’t live forever, and that people can’t expect gold-plated health care and continue to smoke cigarettes, drink a pint a day and pop methamphetamines. Violent sexual predators and murderers don’t need extraordinary care at the expense of responsible citizens so that we can continue to pay for their incarcerated existence. But doctor, you ask, how do we ration or deny care? Who can make such a decision? Isn’t it playing God?

 We already ration and deny care. We just deny that we do it because it’s distasteful to acknowledge and it offends our sense of being compassionate and nonjudgmental. We need to be truly compassionate and rationally judgmental. Any less and we cause unintended harm, harm to which we elect to turn a blind eye. Let’s mandate the establishment of boards of thoughtful, right-minded citizens from the neighborhood, the clergy, the medical and possibly even the legal professions (assuming that wouldn’t grind the process to a halt). With carefully structured guidelines, they would be charged with reviewing end-of-life cases to help physicians provide appropriate care without fear of legal reprisals. This is not tantamount to indiscriminately denying care for all persons over some predetermined age, although it will be interpreted as such by those with an agenda. For our prisoners, the reviewers would have guidelines to permit graded access to care, from simple medications to more aggressive intervention based not solely on the medical illness but on the offenses and sentences of the individuals. This is something that cannot be tasked to physicians, whose professional oath demands equality of treatment regardless of wealth or station.

Did I hear a gasp from the audience? This isn’t as extraordinary a suggestion as it might seem on first blush. Outside of the social context, locking a prisoner up would be kidnapping, and capital punishment, murder. Denying freedom to a felon is accepted as a matter of course. Can denial of certain forms of health care to certain felons be any less reasonable when the consequences of such rationing are of equal benefit to the law-abiding members of society? Like anything else, the “devil is in the details.” I don’t want the government in the jury box, only citizens, peers with solid character. These are difficult but necessary decisions that must be made. Shying away from them will lead only to band-aids and incomplete fixes that will push the problem down to our children and grandchildren, assuming the system doesn’t collapse entirely. And watch how quickly and more haphazardly rationing occurs if it does.

The problem of care for those that are here illegally poses its own set of problems. As mentioned, this might represent 21% of the uninsured. Unless we’re prepared to deport them all (assuming this were possible) the handling of medical care in this population is tied to the greater problem of how to deal with the illegal immigration debacle, and is beyond the scope of this blog. However, there is one bright spot: at least some of this care is already accounted for in the bottom line. It’s being delivered as mandated emergency care provided in the absence of health-care insurance.


NEXT: Untying the Gordian Knot—Putting It All Together


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