Rants and Chants

I recently saw the following letter shared on Facebook and gave it a lot of thought:

During my last shift in the ER, I had the pleasure of evaluating a patient with a shiny new gold tooth, multiple elaborate tattoos 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

Jackson

According to Snopes.com, Dr. Roger Starner Jones wrote the letter “Why Pay for the Care of the Careless?” to the Clarion Ledger in 2009.

After reading this, I came away with far more questions than the answers he provides or implies.

1. Is it professionally appropriate for a doctor to write a letter laced with the sarcasm that he had the “pleasure” of evaluating a patient who he then paints in negative terms?
2. How does he know the gold tooth was “new”? Last I checked, gold teeth don’t have freshness dates stamped into them. Was it 18k, 14k, or 10k? How many ounces? Was it just a gold veneer to cover a bad tooth? What is the real dollar value of it, relative to health insurance or health care costs?
3. Did he get receipts for the tattoos? Does he know she is the one who paid for them? Does he know how long ago she got them? Is it possible she got them before losing her job and having to go on Medicaid?
4. For that matter: Does he know her employment history and how long she has been on Medicaid? Since I know that Medicaid often requires recipients to either look for work or frequently re-verify why they qualify for it, does he know if she has been looking for work?
5. Last I checked, the cost of putting an R&B ringtone on your phone ranged from relatively free (downloaded from a piracy site or using a friend’s, work, library, or your own computer to rip the song from a CD [which, by the way, are available for free use or loan at many public libraries] and transfer to the phone) to about a dollar. Compare the cost of a ringtone to the cost of health insurance and healthcare and the difference will be several orders of magnitude. So is that a valid measure of the patient’s worthiness for Medicaid?
6. Why was this patient at the hospital? Was her illness related to the cigarettes and beer? If not, then Dr. Jones’ argument collapses because despite her unhealthy lifestyle, the patient’s habits are not related to her illness nor her use of Medicaid to pay for it.
7. How would Dr. Jones respond if it were not the woman who came into his hospital, but her dependent child, who might also be eating an unhealthy diet and watching too much TV? Should that child be denied coverage because of the mother’s decisions? And what happens when a child raised in such an environment reaches adulthood and has two decades worth of conditioning guiding their behaviors — as is likely the case with the woman herself?

After pondering those questions, however, I also came up with my own answer to Dr. Jones:

A doctor’s first and foremost concern should be identifying what is wrong with a patient and treating them — both for their physical symptoms and offering them guidelines on how to improve their health. A doctor should not be concerned with the jewelry the patient is wearing or whether or how the patient will pay for their care. No matter how valid his observation may be that some people in our society are living unhealthy lives, this doctor has failed to separate his medical responsibilities from his personal income and has made the far worse mistake of using one particularly notable patient to stereotype everyone on Medicaid.

What if we reversed this? What if, in 1988, I was the patient who saw Dr. Jones? I have never smoked. I do not drink beer. In 1988, I never drank wine or cocktails; today I have either one about 6-8 times per year. Yet in 1988, I did not have health insurance. I could not afford it, plain and simple. When I passed a kidney stone, my family and I needed some financial assistance to cover part of the cost. If this doctor were to take me as the example, what would he say? Would he then support medical financial assistance for the needy? If he is opposing it now and using this woman as an example, wouldn’t he be denying those who might truly need help from getting it?

Since then, my finances have improved. Through income taxes, I have not only “repaid” the assistance, but my taxes have helped other needy people who have been in similar circumstances. But I have also seen first-hand  how horribly expensive health insurance and healthcare can be for even a well-paid person. And even with health insurance, one is not safe from incurring potentially bankrupting costs.

During the last three years, I ran my own business – not by choice, but by necessity. At enormous cost to myself and my family, I provided health insurance through my small business. How much cost? I paid $800 per month for a family of four with a high deductible of $10,000 per individual. So, if my family were in a car accident, we could have faced a maximum out-of-pocket of $40,000 before the insurance would cover anything. Moreover, the $800 per month premium was not all. I also put $480 per month into an HSA account. So I was spending $12,000 per year for health care for my family. That almost equals my mortgage (which, tangentially, is underwater, thanks to Bush-era lending policies that overinflated the housing market.) Do you think this woman, if she eliminated cigarettes and alcohol, could afford $12,000 per year for health insurance? I doubt it. Moreover, even if she could, I know first-hand that it would not buy her much coverage.

Compared to health insurance, the cigarettes, alcohol, tattoos, cell phone, ring tone, tennis shoes,  and even gold jewelry  are relatively affordable.

Over the last half-century, we have created an economy where it is more affordable to live an unhealthy lifestyle than a healthy one. High rewards for malpractice lawsuits have driven up the cost of malpractice insurance, which the doctors and hospitals then pass on to the patients in the form of higher bills. Knowing that the health insurance companies will try to bargain them down, doctors and hospitals knowingly bill higher to begin with, hoping that the negotiation with the insurance company will lead to a fair price. In addition, so as not to be accused of such an overbilling practice, patients without health insurance are charged and expected to pay full price, often with little room for negotiation. Meanwhile, the extremely unhealthy dollar menu becomes all the more affordable to those who don’t have enough money to live a healthy lifestyle.

For their part, patients, especially those with health insurance, are developing an entitlement mentality. If heart surgery will buy John six more months of life with his wife and kids, well, then John  will expect his insurance to cover it. It does not matter to John that the skill level, technology required, and risk level (which has to be insured against a malpractice suit) are all very costly. Those six months will cost tens of thousands of dollars, a cost that will be amortized across the group. But screw the cost and thereby screw the group, John and his family think he is somehow intrinsically entitled to those six months.

Don’t get me wrong: I do not like giving money to people who have consciously made risky or outright bad choices and ruined their own lives. But what is the alternative?

Despite anti-smoking laws, healthy food campaigns in schools, raising the drinking age, etc., we still have plenty of people who make bad choices. And when they get sick, whether we want to pay for them or not, then what? What is your alternative? When someone comes into a hospital, are we supposed to spend an hour evaluating and fact checking his or her lifestyle history? If we do find that they smoke, drink, and eat unhealthy, do we deny them treatment? If not, who pays?

Taken to its logical conclusion, this doctor’s preferences would radically alter our society in ways that would be drastically at odds with the very “free market economy” solutions that the Right talks so much about. It certainly sounds like he would favor a total prohibition of cigarettes and alcohol. He might also not allow people to get gold teeth or tattoos, and perhaps favor some odd laws regarding who can own cell phones or buy R&B ringtones.

If you want healthcare to be available and affordable for all, then we all have to both control and share the costs. If you do not want healthcare to be equally available and affordable to all, then you are the one chairing the “death panel.” You are deciding that someone who smokes or drinks or has an otherwise unhealthy habit (and remember, most unhealthy habits are more affordable than health care) and can’t afford health insurance or health care should suffer and die.

Finally, lest you think in your privileged position of having a good paying job and health insurance that you are not paying a high price for the poor choices of others, just take a long, close look around you. See all of your co-workers? You’re in the same health insurance group as they are. That group may even include employees at other companies who have partnered into the same health insurance program. To cover everyone, all of the individual medical expenses of each person in the group are being amortized across the group. Therefore, when Mary has a heart attack because she eats unhealthy snacks from the vending machine and grabs fast food on her way home from work, each person in the group will be sharing part of her expenses in their premiums. And while she may not have a gold tooth and tattoos, she probably spends plenty of her income on things other than saving up money for the future medical costs that we all face in our later years. And you’re probably not saving up, either. And what about John, your chain-smoking, type A boss, who also has wine with his surf-and-turf, and may have contracted something from his affair with the department secretary. Part of your premiums will cover his herpes meds, his cancer treatments, and his eventual stroke. They may not be on Medicaid, but the group premium you pay isn’t just to cover your costs; it will cover John and Mary and leave the insurance company a “healthy” profit, as well. So why should you begrudge this woman in Jackson, Mississippi her equal access to affordable healthcare?