This past weekend I had the pleasure of talking about Obamacare (or the ACA, the death, the uplifting of America, depending on your stance) with a stranger at a local brewery. He, like many I’ve heard before him, feels that he shouldn’t have to pay for other people’s care (which he already is, in a different way). Not their blood pressure meds for self-induced diabetes, not for oxygen for a 35 pack-year smoker, and not for birth control for a jobless mother of five. And he certainly didn’t think the government should be penalizing for not buying into the system. In many ways, we saw eye to eye. In others, not at all. In this essay, I plan only to discuss some of the theory and finances of the ACA, not its website woes, which are plenty.
“They have to learn a lesson sometime, right? We can’t just keep picking them up and making them even more dependent on handouts, right?”
There’s a well studied phenomenon in third-year medical students that came to mind after talking with the stranger: compassion fatigue. Sometime around February of our third year we stop feeling empathetic for patients, and I think I know why. We suffer from caring for a horribly sample-biased population of miscreant, irresponsible, obese, self-harming, “entitled assholes.” (I say sample-biased because only around 10% of the population is hospitalized per year, so we think everyone is that way, though it’s only actually a single digit fraction of the normal populace that lives this way.)
It seems the world is packed to the brim with these jerks when your perfectly capable patient decides they’re just going to pee themselves instead of getting up to use the toilet because they like being cleaned by the nurses. Or your morbidly obese diabetic patient has a fungal infection between their fat folds, which you inspect and discover that they actually also have necrotizing fasciitis from MRSA, which is news to them, and a fistulous tract down to their groin. You can’t help but think to yourself, “what kind of life form is this?”
“Teaching” a Sleeping Classroom
I mention these examples because the problem, my dear Obamacare-hating friends, is far, far worse than you know. (To those medical students reading this, I hope to convince you to draw an alternate conclusion from the one that many of us have drawn.) You think these patients are just welfare-based “societal parasites” who need the right kick in the rear to “learn their lesson.” Denying insurance coverage for the contraceptive IUD for a mother of four will not teach her anything about family planning. Rather, it will put another human on welfare, who you’ll pay for, as well as her hospital stay when she has to have a crash-C-section because her blood pressure is through the roof and her placenta tears off during labor.
It is, in many ways, quite simple: many humans have far less insight, and have far less will to change than the “lesson-teachers” believe. Indeed, given all the data, it appears that this mother of four is unable to learn this family planning lesson at all. To my ears, your insistence that we “teach a lesson” to a classroom of thoroughly apathetic pupils—this subset of our patients—seems to lack the very insight you aim to impart. We get to foot the foster-care, welfare and hospital visit bill (via $115 billion in Medicaid payments) for that woman and her family because we’re “teaching a lesson.” This is why we must make it so easy and so affordable to get contraception (and a primary care doctor who can try to keep track of all the family’s preventive care needs) that it’s almost easier to take the care than put it off until the problem explodes. Denying this preventive care strikes an oddly sinister tone to my primary-care-bound med student mind. As my friend Paul H. put it, “I hate lazy assholes. But I hate evil ones even more.”
Removing Barriers … or Taking Control?
Finally, a little more perspective: we’re only talking about 15% of the population that is in need of health insurance. This is a lot of talk for something that might not actually cause that big of a financial gain (or loss) even if it works (which is also heavily dependent upon a seemingly mythical functional website). And one-third of that (or 5% of the total population) accounts for 50% of health care spending. If we remove all the barriers to preventive health care, we can take control of the health of those who very clearly have no ability nor interest in doing so themselves. This is one of the darker reasons why I am behind the Affordable Care Act.
“Teaching them a lesson in insight” only hurts people, their wanted or unwanted children, and is devoid of the very insight we’re aiming to teach. As I begrudgingly agreed above, some of these people at the bottom seem to be selfish assholes, on disability for completely self-induced diseases (overeating, sedentary lifestyles, drinking, smoking induced neuropathy, the list goes on), and its about time we took control of their health by removing barriers to preventive care that would keep them out of the hospital for longer.
With the ACA, Medicaid reimbursements to primary care providers (PCPs) will grow to match Medicare reimbursements, which will increase the number of PCPs who take Medicaid. Along with an increasing role of mid-level providers (nurse practitioners and physician assistants), the US health care model will shift from provider-driven sick care to patient-driven health care (thank you to Kaufman Hall and my uncle Steve for this). Thus, given a generation or two, our communal economic burden of social welfare will be better for it. Better yet, fewer people with these problems will exist, because fewer of these problems will have popped up in the first place.
So, to my microbrewophile friend, you’re already paying for their care and their children. What I’ve laid out here is a forecast for suffering and prevention that most anyone can get behind, even those who wish to teach lessons by denying care. Let’s not continue banging out heads against the wall, surprised that the pains of that 5% haven’t cleared up yet. Let’s give a little bit, and empower the uninsured to take control of their health.