Wednesday, February 17, 2010

Why Pay for the Care of the Careless?

Why Pay for the Care of the Careless?
August 23, 2009 by Dr. Roger Starner Jones

During my last shift in the ER, I had the pleasure of evaluating a patient with a shiny new gold tooth, multiple elaborate tatoos and a new cellular telephone equipped with her favorite R&B tune for a ring tone.

Glancing over the chart, one could not help noticing her payer status: Medicaid.

She smokes a costly pack of cigarettes every day and, somehow, still has money to buy beer.

And our president expects me to pay for this woman's health care?

Our nation's health care crisis is not a shortage of quality hospitals, doctors or nurses. It is a crisis of culture — a culture in which it is perfectly acceptable to spend money on vices while refusing to take care of one's self or, heaven forbid, purchase health insurance.

Life is really not that hard. Most of us reap what we sow.

Starner Jones, MD

Doctor Jones was right, and should be commended for publishing his comments. We were told to be outraged that banks, insurance companies, auto-manufacturers and other businesses got a government bailout. The issue was that bad decisions have negative consequences, and that to protect these mega-corporations from the consequences of their own actions was not only unwise (encouraging them to continue making bad decisions) but that it would unjustly shift the burden of responsibility from those who made the mistakes to all the rest of us who were the victims of those decisions.

This problem is precisely what occurs when individuals are bailed out as well. I don't know anyone who objects to helping those who cannot help themselves, even with expensive health care. But I know many people, myself included, who do have a problem with forcing the rest of us to help those who simply won't help themselves, such as the woman in Dr. Jones' example (and let us not pretend this was only an isolated case). If it is outrageous to spend hundreds of billions of tax dollars to bailout irresponsible businesses for making bad decisions, it should also be outrageous to spend hundreds of billions more in tax dollars to bailout millions of irresponsible individuals for making bad decisions.

And that is the underlying problem: government is rightly expected to be responsible with the people's money. This oversight (although selectively applied) requires endless strings, bureaucracy and red tape. And that is why America's founders set up the Constitution so the federal government had no place in any of the myriad social programs we pay into today. Retirement, education, health care, etc., is supposed to be the realm of the states and the people, not of the federal government. If you want your state government to handle your health care, public education, Social Security and other aspects of your life, fine; but get the federal government out.


  1. Dr. Jones,

    Your comments made a lot of sense. Would you consider posting on my BLOG? I have listed you in my twitter health care list.
    health care-pparris9


    Pat Parris

  2. I give in!

    Let's pass it, but let's also continue to work on making health care something that we can pay for as well as benefit from. Let's continue to work on developing technology with an eye toward cost savings as well as health care.

    I think regulation on alternative medicine should be loosened to emphasize comfort over cure.

    I think that insuring 30 million Americans is worth the risk of a few bad apples if there are incentives put in place to stop abuse.

    The respect the economists in the NY Times article. There is no reason why medicare can be fixed and defensive medicine corrected after this bill is passed.

    Our President has done a masterful job of bring the stake holders together. Although I think the summit could have taken place with a caucus process. (See my previous post) I believe that he make the changes necessary to the health care bill after it is passed.

  3. Dr. Jones's article offends me, especially his "reap what they sow" line. I guess his feelings are understandable. It's easy to become defensive when one's livelihood is on the chopping block , but his proposed solution reeks of a "let them eat cake" snobbery. No wonder Republicans are viewed as the "uncaring" "out of touch" party.

    Stripping away the rhetoric, he proposes that the lady purchase health insurance by eliminating certain objectionable vices --- a gold tooth, a few tattoos (no description of how elaborate the artwork was--some tattoos are quite cheap), cigarettes, beer, a cell phone with an R&B ringtone. How much does all of that really cost? Compare that to the 2 ER bills he and his hospital would send her if she didn't have Medicaid to pay. The vices pale in comparison. But, he didn't suggest that she do without the vices and instead pay his bill herself. Rather, he suggested that she do without the vices and "heaven forbid, purchase health insurance." Well, let's take a look at that.

  4. Health insurance is a recurring cost. If you can't pay it every time the premium is due, it will lapse. Most of the "vices" listed in Dr. Jones's article were one-time costs, and there is no indication that they were obtained all at once or whether the lady even paid for them herself. They could have been a gift from a boyfriend or a relative. Or they could have been paid for one at a time, with many months of saving n between. Most of the items he objects to are fairly cheap. If a person has a legitimate need for dental work, how much more is a "gold tooth" vs. one that matches the pearlie whites, anyway? I wouldn't be surprised to learn that selection made by the good doctor's patient was actually cheaper than the one his wife would have chosen for herself if the need were to arise. And, why does he begrudge her the "R&B ringtone?" It's 99 cents, for Pete's sake!

    The only recurring cost in Dr. Jones's list of horribles is the beer and cigarettes. A 6 pack of expensive craft beer is $8.00. I doubt she was buying the good stuff, but we'll use that figure. I have no idea how much cigarettes are going for these days. We'll use $5.00 a pack. Assuming a pack a day habit, that's $150 per month. Dr. Jones didn't indicate how much beer he thinks she consumes, so I'll assume she sucks down a six pack every day. That's another $240.00 per month. So far, that's just under $400 per month. Again, that pales in comparison to the cost of an individual health insurance plan that has coverage comparable to Medicaid.

    But, the good doctor is right about one thing. "Our nation's health care crisis is not a shortage of quality hospitals, doctors or nurses." I don't think there's anyone saying otherwise. The problem is incredibly complex. In part, it's because the poor are routed to the ERs in the first place. They are routed there because they are the one place that will accept a walk-in with no insurance. But, ERs are the most costly source of health care. So, when the bill does come due, it's way more than it needs to be. That brings me to my next complaint. Hospital's bills are incomprehensible, and the charges often aren't disclosed until after-the-fact. That's not exactly the best bargaining position for a patient to be in.

    There's the dreaded pre-existing condition problem and the fact that insurance companies get to decide what they will and will not cover. And, in most circumstances, even when their decisions not to pay are completely contrary to what the plan calls for, there is very little that can be done about it.

    And, most significantly, the health care crisis stems from the fact that for most people, their health insurance coverage is tied to their job. If their health gets bad enough, they will likely not be able to work, and their eligibility for coverage will end just when they need it the most---even assuming that they can afford to pay their premium at that point. So, for most, health insurance is like an umbrella that melts in the rain.

  5. I partially agree. The "reap what they sow" idea does seem like an attempt to oversimplify the situation. The fact that our society wants to apply this philosophy to mega corporations doesn't make it okay to apply it to individuals in all cases but I would like to see some consistency. Protecting individuals or businesses from their own decisions eventually leads to disaster.

    Another issue at hand is the positive presumption for the individual but negative presumption for corporations. Indeed ER health care is sometimes the only option for those without health insurance, which is indeed the most expensive type of care. But let us not presume the patient Dr. Jones mentioned exercises regularly, utilizes a well rounded diet, drinks plenty of water everyday and otherwise makes healthy decisions (such as abstaining from substance abuse). The individual vices Dr. Jones mentioned may not add up to much in and of themselves but the health impact of some of those certainly do. And the signs the good doctor noticed are perhaps cliche, but none-the-less indicative of a lifestyle that greatly increases the need for medical attention. One might also ask if the woman has a cellphone service with texting and multimedia, cable TV and high speed internet. Or how about the wardrobe that "must" be keep up to date?

    The details immediately available may not stack up by themselves but with clear evidence this woman was concerned about staying "hip" I think the principle still stands. We tend to presume the best of the individual in such situations but often presume the worst of business. After all, if there is any financial incentive to abuse people shouldn't we presume the opportunity will be exploited as industry standard practice? (doctors have financial incentive to perform unnecessary procedures, lawyers have financial incentive to prolong cases, teachers have financial incentive to NOT teach students, and politicians have financial incentive to NOT fix problems)

    However, I think the description of an umbrella that melts in the rain is quite clever and particularly apt. "Health insurance" is such a misnomer it might as well be false advertising. Health insurance could be treated as the equivalent of all other types of insurance one might purchase for one's property combined - home, auto, etc. By this I mean we don't buy homeowner's insurance to protect our cars; and unless you get some kind of full/universal coverage on your house there are usually many calamities not covered by the insurance plan. The insurance we get to cover our property is more of a "just in case" type coverage. Health insurance doesn't work quite that way. There may be a pre-existing conditions loop hole but if that's not an issue when you get health insurance, the coverage plan is supposed to cover pretty much what ever happens to you - effectively a near-universal plan.

  6. In any "just in case" scenario there is a fair chance nothing will happen, such as flood insurance. But with health insurance, something, SOMETHING, is virtually guaranteed to happen at some point. With the insurance model that means premiums rise. Plus, we have the third-party-payer factor; when people do not keep tabs on their own expenses (meaning we become far more likely to use health care when we really don't need to) and let someone else pay those expenses (meaning they reserve the right to decide what they will pay for) prices rise. Lawsuits (yes, lawsuits) are another major expense. Sometimes lawsuits are the right thing to do, and sometimes they are frivolous and sometimes they are a scam. With such a litigious society, this makes prices rise, especially when medial professionals prescribe needless tests just for CYA measures.

    Have you seen the corporate headquarters of an insurance company? Do you know how many people are employed at insurance companies? What pays for those employment expenses and those big buildings? The people do, via insurance premiums. And how much do doctors get paid by those insurance companies? Something like 75% of the official service fees? It makes sense hospitals would artificially inflate their fees in this situation.

    It is a complicated issue, one with perpetually rising costs due to many reasons. That's why, I believe, the insurance model will eventually collapse under its own weight. This is why it makes no sense for the federal or state governments to require the people to buy insurance of any kind - that feeds the problem (and business and political interests) but this is not a solution.