I have struggled with the question posed to me by numerous people over the last several years. “Do you believe health care is a civil right?” In the U.S. this is a key question. We have long had a law in place (EMTALA) that mandates that any hospital emergency room that accepts government payment for services, i.e. takes Medicare or Medicaid payments, must provide emergency care for anyone who shows up regardless of their ability to pay. This sounds like the government feels all persons in the U.S. have the right at least to emergency care. Because of this regulation emergency rooms have become the primary care providers for many Americans. If you cannot afford health care all you need to do is show up at an ER and you will receive at least urgent types of care. The cost of this uncompensated health care is made up by those who do have a way to pay for their own emergency care being charged higher rates. In essence the law mandates that everyone has a right to health care and that those who can afford health care must pay for the emergency care of those who cannot afford it themselves, a type of behind-the-back mandate.
It is difficult to argue that receiving all of your health care at emergency rooms is serving anyone’s best interests. Patients get at best piecemeal and intermittent care. The costs of any single episode of treatment in an emergency room is far higher than at a primary care office. Continuity of care does not happen at emergency rooms, because by definition ERs are for emergencies, not ongoing disease management or preventive care services. So what has been happening in the U.S. for years is lousy primary care in emergency rooms under government mandate to provide it paid for by everyone else who pays health insurance premiums or pays for their own emergency care.
So after considerable thought, perhaps spurred by the recent Supreme Court ruling upholding the constitutionality of the Affordable Care Act, I have concluded that unequivocally yes, I do believe that health care is a basic civil right in the U.S. Although there has not been a court ruling or a constitutional amendment clearly upholding that right, I believe we as a country are nearing the time when we need to openly face this fact. As the most powerful, arguably the wealthiest, and hopefully among the most compassionate nations on earth we need to face our civic responsibility and find a way to provide health care to all of our citizens.
How to meet this responsibility is very much open to debate. It seems that unlike every other first-world country we are not ready to have a single-payer system yet. Neither political party seems ready for this, and I don’t hear any widespread grassroots outcry for a single-payer system. So what do we need? We need our elected legislators and president to govern. We as citizens need to demand that our elected leaders stop the partisan bickering and posturing and govern.
I remember even 20-30 years ago our leaders somehow found ways to compromise and find common ground from which to make progress toward trying to solve problems. Now it seems that our elected leaders are so focused on pleasing elements of their political parties that they cannot risk even trying to find areas of agreement on which to base legislation and compromise.
It seems that it is more important to politicians today to make their opponents look bad than to risk sharing credit for good policy. Is this just a pipe dream? Will it take a yet more eminent fiscal crisis to force our elected leaders to take the needed risk and find a way to get this done? Probably yes, but it is likely to be sooner than anyone expects.
I also understand that healthcare is just one of many pressing crises facing the U.S. Still it seems like one where it should be possible for our leaders to find solutions on which members of both parties can agree, and where we can expect progress acceptable to elected leaders of both parties. We just need them to stop fearing the radicals in their own parties more than they fear doing nothing in the face of crisis.
Let’s all tell our elected officials that if they don’t begin to find ways to put the needs of our country, states and cities ahead of partisanship that we will never vote for them again, and will keep electing new people until we find ones who will try to govern with courage and compassion.
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On a somewhat related topic I enjoyed reading the commencement speech by Donald Berwick MD to the Harvard Medical and Dental Schools graduating classes this May published in JAMA.
By Donald Berwick MD, MPP
June 27, 2012
Thank you for letting me share this glorious day with you and your loved ones. Feel good. Feel proud. You’ve earned it.
In preparation for today, I asked your dean of students what she thinks is on your mind. So, she asked you. The word you used—many of you—was this one: Worried read more