We all know, and probably all periodically use the expression: for goodness’ sake! Perhaps it represents well the prevailing cynicisms of modern living that when we say “for goodness’ sake” these days, we don’t really mean doing something for the sake of its intrinsic goodness. Rather, we use “for goodness’ sake,” when we aren’t using less savory language, to vent exasperation.
I will borrow both the original denotation, and the current connotation of this idiom to make a case for universal health care coverage. Connotation, because yes, as a public health professional, I am more than a little exasperated with us. Denotation, because yes- this is something we should do for the sake of goodness first and foremost.
So, let’s start with actual goodness, which maybe should come first routinely for its own sake. Our public discourse, and more often discord, about health care coverage rarely seems to consider it. But the provision of universally accessible medical care is first and foremost about goodness at a fundamentally human level.
We all agree, so far as I know, and across the expanses of politics and party, priorities and preferences, that any acute medical calamity warrants an acute response not subject to a financial test. The pedestrian struck by a car; the victim of a car crash, or shark attack; and the more frequent, sudden drop from heart attack or stroke precipitate emergency responses, and emergency care. The bill eventually comes due, and is generally very high- but it’s not a factor in the initial delivery of care.
By itself, that makes so-called “health care,” and more aptly “disease and injury” care, different from any other free-market choice. There is nothing else we “shop” for while unconscious; very little else we must “buy,” or die immediately.
Such basic exigencies as these make health care unique relative to anything else we purchase. But not unique relative to everything; it falls in a category. That category is public good.
Our protection by police is a public good. So, too the protection of our homes and forests by fire fighters. And of course, so is the protection of our borders by the military. The U.S. Military cannot possibly defend our borders for some of us without doing so for all of us; it is a public good.
So, too, are the diverse components of first and emergency medical response.
Emergency medical care is a public good. The only alternative to that is a society where a financial test is applied before care is rendered to an 8-year-old hit by a car on the way to school. I hope and trust our common humanity recoils at the prospect. Assuming it does, then urgent and emergency medical care becomes a human right. We should treat it as such.
Once we do, there are two immediate implications that nudge us toward a short but slippery slope. The first is that we are going to cover the costs of emergency care for all who need it one way or another, either rationally, or irrationally. The second is that universal coverage of emergency care without universal coverage of preventive care is a guarantee of more emergency care needed, at higher cost. It is the classic case of penny wise, and pound foolish- the failure to obviate costly pounds of cure with ounces of prevention. Let’s briefly consider both.
If the ethical positioning of emergency medical care as a human right is formally recognized, it permits us to plan accordingly. We could acknowledge that such care will be provided both to those who can pay for it, and those who cannot. This, in turn, allows us to determine in advance how best to distribute those costs. The answer is the obvious one, derived from the most relevant precedents: much the way we cover the costs of our military protection. Costs for a given year are estimated and projected, and all who can pay, do- in our taxes. We understand and apparently accept that the military protection our taxes cover will cover those with no means to pay any taxes, too. Such is the nature of public goods.
This approach does not, of course, spare us the need to pay for others along with ourselves. But it does distribute those costs widely, and in the most equitable manner possible. The alternative, applied uniquely to health care, is to make no advance plans for distributing the costs incurred by those unable to pay, and then directing those costs haphazardly after the fact. The results generally range from painfully irrational, to overtly tragic- as when a much-needed hospital serving an indigent community is put out of business.
The costs of emergency care for all cannot be avoided by any society of the decent and humane. The only choice is to handle them rationally, or irrationally. The U.S. has opted for an irrational approach, paying for the folly of it in both dollars and lives. Even the Affordable Care Act is only a partial correction, but vastly better than the absence of any correction at all.
The second key consideration as noted is the choice between penny wise, pound foolish, and in-for-a-penny, in-for-a-pound. The latter is the obviously logical of the two for health care, as for other public goods.
Imagine, for instance, if we all agreed that military defense was a public good we, the people, should pay for on behalf of all- but only in response to emergencies. This would mean we would cover military responses to attacks, but we would not cover intelligence gathering or surveillance of any kind, because these are preventive measures. We would not pay to prevent the next 9/11, we would just pay to clean it up.
Such are the implications of covering emergency medical care for all, without covering preventive care. Preventive care, from cancer screening to immunization, is to medicine what surveillance, treaties, NATO, the United Nations, and intelligence gathering are to the military. Viewed that way, the folly of leaving them out of the planning for public good is, I trust, self-evident. Imagine a military that never did anything at all until after we were attacked and imperiled, and ask yourself if that’s a satisfactory use of your tax dollars.
In case you are wondering, yes, we do have a source of the reliably evidence-based preventive services that contribute meaningfully, and cost-effectively, to the public good. The verdicts of the U.S. Preventive Services Task Force do not tell us everything we need to know, but we certainly need to know, and should cover, everything they tell us.
What stands in the way of progress and rationality is a toxic blend of cultural arrogance, misguided ideology, and selective blindness. The United States spends more on health care to achieve worse outcomes than many of our peer countries around the world, yet the arrogance of a “not invented here” mentality seems to preclude us from examining and adopting elements of best practices developed elsewhere. The contention that universal health care coverage is in any way more socialistic than universal military protection is not just ideological nonsense, but nonsense inconsistently applied. The failure to note the place for medical care among other public goods is selective, cultural blindness induced by the glare of ideology where epidemiology should be, and often by willful distractions, distortions, and overt deceptions.
The fate of the Affordable Care Act specifically, and health care coverage in the U.S. generally, are highly uncertain at present. All of the dialogue, however, seemingly begins with medical care as a discretionary commodity, and that is egregiously misguided. The ACA is less than it might be because it was the most that could be done in a culture that has never managed to position medical care where it obviously belongs, among other public goods. Doing so would open the door to innovative models that could shop the world’s pearls, and string them in a uniquely American way.
Any such system, promoting preventive care for all, would save lives. By reducing the burden of preventable disease, such a system would save money. By applying best practices from elsewhere, such a system would add years to lives as well as life to years. By distributing inescapable costs rationally, such a system would save hospitals.
Such possibilities begin with a cultural reorientation: medical care is a public good. There are many good reasons to preserve and improve the Affordable Care Act, and dollars figure among them. But first and foremost, we should do it for goodness’ sake.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and current President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.