Being Thankful for the Uninsured

Posted on December 1, 2008
Filed Under General Rationing Issues, Healthcare economics |

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Gathered around the Thanksgiving table last week, DrRich’s large extended family, carrying out a longstanding tradition, each offered in their turn one reason for being thankful on this most reflective of American holidays. DrRich listened respectfully as each of his loved ones, and each of the ones he was obligated to tolerate benignly because they had married (or in some other manner had committed to) one of his loved ones, recounted a cause for thanks. There is no need for DrRich to recite their utterances here, because they were all perfectly predictable and fairly mundane, having mostly to do with items such as maintaining good health, finding a job, being able to afford one’s mortgage payments, getting a passing grade in French, receiving a new puppy, Mr. Obama’s election, the apparent continued structural integrity of the Universe despite Mr. Obama’s election, etc., etc.

When it was at last DrRich’s turn, he, in retrospect perhaps somewhat inadvisedly, was unable to refrain from displaying his keen insight and superior analytical abilities on matters related to healthcare (a topic, anyone would have to admit, about which most of us would very much like to feel thankful). Lifting his glass, DrRich pronounced that he was most deeply and humbly thankful for the 47 million Americans without health insurance. And even though that number - 47 million - must surely be growing, given the recession, advancing unemployment, imminent collapses of businesses and indeed entire industries, etc., DrRich went on to express his fervent wish that the uninsured might still be with us a year hence, despite all the talk of healthcare reform that threatens to greatly diminish or even eliminate their ranks.

Enjoying the remainder of his Thanksgiving meal out on the back porch with the new puppy, DrRich composed in his mind this explanation which you now behold for the keen appreciation he has developed for the uninsured. He now offers this explanation both to his readers, and to the few members of his family who, he believes, might have been inclined to hear him out, had Mrs. DrRich not offered at that moment to consider remaining married to him only if he would retire from the table immediately. (Believing his marriage to be a union sanctified in heaven, he did so.)

In any case, for those who have an open mind, there are two compelling reasons we should be thankful for the uninsured, and should be particularly loath to allow them to disappear.

The first reason DrRich has mentioned before: It is largely thanks to the uninsured that we are able to maintain the fundamental and dearly-held American fiction that there need be no limits on healthcare. (The image DrRich conjures up when he says “dearly held” is that of Gollum caressing the Ring.) Simply put, when we have tens of millions of uninsured Americans who don’t have ready access to regular and routine healthcare, then it’s relatively easy to pretend that “healthcare” should include everything we might want it to include.

Our current healthcare system relies heavily on using the uninsured as a huge fiscal safety valve. That is, in  lean times (such as now), we open up the valve, increasing the number of people who are ineligible to consume routine healthcare. Increasing the number of uninsured Americans has become perhaps our most effective mechanism of covert healthcare rationing.

This simple expediency alone goes a long way toward enabling us to avoid having to consider or discuss limits. Openly recognizing the unavoidable limits to healthcare, much less having to figure out how to implement such limits fairly and rationally, would be exquisitely painful and disruptive. (Just ask Gollum how unpleasant it is to be forcibly separated from that which we deeply value, such as our “no limits” paradigm of healthcare.) For helping us to avoid such pain and societal disruption, we clearly owe a great debt of thanks to our uninsured brethren.

The second reason came to light recently in an article in the Journal of the American Medical Association.* This article showed that, contrary to both popular lore and to stern pronouncements by every policy expert bent on convincing us that (next to global warming) reducing the number of uninsured Americans is the most important task of mankind, the overcrowding in American emergency rooms is NOT due to the uninsured. Rather, it is due to insured Americans who cannot get in to see their primary care physicians.

DrRich and many others have discussed at some length the “primary care problem” and its causes. That is a very important topic, but it’s not the topic of this particular posting. This posting is about the great and abiding value of the uninsured.

It really should not be a great surprise that ER overcrowding doesn’t have all that much to do with the uninsured. While it is difficult to generalize about such things, a large proportion of the uninsured are people who have assets. (If they had no assets they likely would be eligible for Medicaid.) That is, they are people who have jobs, homes, cars, etc., but their employers (who, in many cases, are themselves) cannot afford to provide them with health insurance. The chief point being, of course, that these individuals have something to lose.

These are not the people who will voluntarily enter an emergency room for their healthcare, at least, not for a medical problem that they can somehow convince themselves might go away on its own if they give it a chance (such as, perhaps, crushing chest pain, or paralysis of the left side, or some other such eventuality which might cause some of us less circumspect, more insured people to just go ahead and dial 911, all willy-nilly).  They realize that the moment they set foot into an emergency room they will mount a bill of at least several thousand dollars, which they will either have to pay, or spend months or years fighting off the increasingly aggressive bill collection professionals being dispatched these days by their local hospitals. They are putting their assets and their futures at risk if they come to the emergency room.

Rather, the overcrowding is due to people who have insurance - whether it’s Medicare, Medicaid or private insurance - and who are therefore entitled to their healthcare by whatever means they calculate is the most convenient for them. Increasingly, because primary care practices are hard to find, are booked for weeks in advance, and are less and less user-friendly by the day, the convenience calculation tends to default (incredibly) to the emergency room. (That insured people are choosing emergency rooms - notoriously one of the most unpleasant experiences American citizens can encounter in peacetime - instead of primary care offices should itself set off major alarms about the state of American primary care.)

This is all fairly intuitively obvious, and the JAMA article really should surprise only those who habitually believe the “official” truths being promulgated today by politicians, media, and various authorities on healthcare.

It should be plain that suddenly providing 47 (or 50) million Americans with health insurance will decidedly not relieve emergency room overcrowding, as the policy “experts” all promise us (the same experts, apparently, who promised us that the $700 billion bailout would avert a stock market crash, and who confidently spout a host of predictions which fly in the face of history, common sense, and laws of economics, physics, and human nature). On the contrary, creating tens of millions of newly insured individuals, without simultaneously revolutionizing our attitudes and policies toward primary care medicine, will quite obviously make our already overcrowded ERs absolutely burst at the seams, and render even more hellish than it is today - even deeper down within “grief’s abysmal valley” - the prospect of entering such a place.  Indeed, if we suddenly insure all these people, the rest of us who currently have insurance really won’t have anywhere to go to get our healthcare.

So. QED. As DrRich said at the Thanksgiving meal, thank God for the uninsured.

Clearly if DrRich had been permitted a mere five minutes to explain himself, not only might he have avoided eating runny mashed potatoes in a steady drizzle, but he also might have salvaged his reputation among some of the more remote members of his extended family, who really don’t know what a swell and reasonable guy he can be. Next year when his turn comes, DrRich will choose to be thankful for some more traditional value, in the hopes of being allowed to eat his meal in a warmer, drier, friendlier environment - perhaps, if current trends hold, he can be thankful for the final demise of the evil health insurance companies.

* Newton MF, Keirns CC, Cunningham R, et al. Uninsured Adults Presenting to US Emergency Departments: Assumptions vs Data  JAMA. 2008;300(16):1914-1924.

Comments

5 Responses to “Being Thankful for the Uninsured”

  1. BladeDoc on December 1st, 2008 3:52 pm

    How is it possible that you can depress the crap out of me and make me giggle at the same time? Bravo sir, Bravo.

  2. Dr. Val on December 1st, 2008 6:57 pm

    BladeDoc - you should read Dr. Rich’s book. My comment to him was that it should be bundled with an antidepressant (pretending for a moment that those drugs do what their name suggests). Yet, you have to like the guy because he’s right about most things (I only say “most” because it’s impossible for me to evaluate the possibility of him being right about all things). :)

  3. BladeDoc on December 1st, 2008 7:14 pm

    Yep, read it and have given two copies as gifts (one to my hospital ethicist). Once you start looking through the lens he provides it’s impossible not to keep tripping over examples.

  4. DrRich on December 1st, 2008 7:15 pm

    BladeDoc and Val,

    I try very hard to mask with humor (of a sort) some of the exquisite sadness that one can experience by understanding the healthcare system, both on the blog and in the book. That my humor tends to be of the ironic variety, and is therefore sometimes misunderstood by some readers (though not ever by either of you) is a great source of entertainment for me, and in that way dulls the sharp edges of seeing American healthcare as I happen to see it.

    Rich

  5. Dan on December 2nd, 2008 2:02 pm

    We’ll set a place for you at my family’s table next year, since they regularly suffer through my rants about the failings of the health care system.

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