Lots of talk this year about healthcare. All of which culminated in the big health care huddle at the Blair House on Thursday. The fundamental differences were, in my opinion, pretty well articulated and I believe they represent honest beliefs. I think the Republicans are honestly weary of putting the federal government in charge of anything, let alone something as big and complicated of as our healthcare system. I also believe that Democrat’s honestly feel that one mark of good society is one in which everyone is taken care of. As I said, both beliefs are honest and both have their substance in good intentions.
Unfortunately, what we have now is neither system. In fact, we have the worst of both worlds. We have socialized demand with a free market payment system. Anyone can get treatment in America by presenting to the Emergency Department and that hospital will take care of them. Often to great lengths and at great cost. If a woman presents in active labor, she will be attended to by full staffs of doctors and nurses. Should the child be premature and need to go to the neonatal intensive care unit (NICU) the newborn will get that. Is this wrong? Should we deny these people treatment? Should we give them some treatment, but draw a line somewhere in the sand? How do you tell a mother that she does not have the cash needed to run the incubator?
So, in reality, few of us have actually seen free market medicine in its entirety. It does exist though. It can be found in the poorest parts of the world. During my six month tour in Afghanistan we came face to face literally with this. I saw a world in which people truly got what they paid for and nothing more. Families frequently chose to go without in order to save for a chance to see a doctor. Sometimes this would involve also saving up for long trips in the hopes of finding treatments. The more money (or land, or corn, or poppy) you had the better treatment you got. Now this treatment was nothing compared to our system, but some medical facilities were better than others.
Once the Western World showed up in the form of NATO the medical capabilities in the area increased exponentially. In was not uncommon for a Battalion level Aid Station to be the absolute best treatment available for many miles. As such, individuals would approach the gate and ask to see us. Providing medical care is good PR and an excellent aspect of Counter Insurgency Operations (COIN), but it was a fine line. If we provided care to everyone, for everything, on demand we would not only run out of supplies but we would also create a culture of dependence. Our main goal medically and tactically was to connect the people to the Government of the Islamic Republic of Afghanistan (GIRoA). Our CO laid that out to everyone in the unit constantly. It drove every decision.
So we ended up seeing a lot of people and treating many, though not always all. Life, limb or eyesight was always taken care of. Children were taken care of. Any injury that was or could have even possibly been caused by NATO forces was treated as well. But there was a good many things we could not assist with. Usually these were chronic conditions that we, as a BAS did not have the supplies required. Seeing human beings in this state and turning them away is not easy. We even saw a man bring his mother in with radiological results from tests done in Pakistan diagnosing her with throat cancer. He came hoping we could do something. Unfortunately we had absolutely nothing to help her and we had to turn her away.
In Afghanistan, especially prior to our arrival, it was just “the way it was”. People just lived and dealt with their conditions. If they were bad enough, they just died. This happened to young and old, men and women. By disease and by accident. And sadly often times by war related trauma.
True free market medicine is a difficult thing to look at. That’s why we as a country have made ethical decisions to treat everyone that shows up at our hospitals. But when we do that, who actually pays the bill? It falls on either the government or the hospital. Neither of which is in a financial position to handle these expenditures.
So when we talk about peoples right to health care, we must decide at what point the right stops and the privilege starts. Does the man above have a right to cosmetic surgery? Would he have had a right to the treatment years ago before his conditioned worsened? One thing that free market medicine in Afghanistan has done, is made it easier for people with debilitating conditions to remain engaged in society. Could you imagine seeing this man in your supermarket? Would a person with his condition ever be employable in the United States? The fact of the matter is, we have different standards in the west. We would look at him and wonder why he hasn’t gotten himself taken care of, and never thought that maybe he just couldn’t afford it. So if we go straight up free market, we must prepare ourselves for sights that, although common in the poorer sections of the world, are relatively uncommon here. In Afghanistan this is just part of life.
Lest anyone think this blog is coming out completely in favor of socialized medicine, the fact is we also saw the other side of the spectrum while deployed. Once the local population found out we had medical capabilities we also saw an increase in people coming to the gate, “just because”. Those members of the Afghan National Army that were colocated with us were even worse, coming to the BAS for minor scrapes and belly aches that we, in this country, would just deal with ourselves. There is no doubt that low prices increase demand and making something free has the paradoxical effect of increasing demand while driving down the perceived value. We see this already in the United States with people activating 911 for a “free ride” to the hospital without knowing or caring how much the service actually costs. To them it’s not only free, but a service they feel entitled to.
So, what we have in America right now is system that allows access to patients regardless of their ability to pay. Those least likely to pay are also least likely to use the system efficiently and least likely to prevent problems from occurring in the first place. We also have medical professionals who must practice defensive medicine, because even those with no ability to pay, retain the ability to sue. Our “free market” medicine is really limited to preventive measures and cosmetic measures for those who can afford it. The rest of the system is already socialized to a large degree. This complete imbalance leaves organizations like your local community hospital struggling to figure out how to expand to meet demands (based on patient load as well industry quality standards) without any increase in revenue.
The system is most definitely broken, but the solution is not as simple as either side would make it out to be. I think the answer lies in a little bit of everything. We need tort reform and we need better preventive services available for all. We need to ensure that people are covered in some way in order to improve the pay for services aspect. We need to bring a more consumer driven approach into health care decisions. We need to clearly define the line between rights and privileges of health care and we need to prepare ourselves for the sight of some people being turned away from hospitals because they either are not sick enough or don’t have the money. I don’t pretend to have the magic wand, but I know that unless the Congress and President embrace the entire reality of the situation as opposed to only the reality they agree with, we will not find the happy medium. Holding fast to talking points will not cut it.