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Excerpt From 'The Truth About Getting Sick in America: The Real Problems With Health Care and What We Can Do'

A doctor weighs in on the morality of the American health care system

Tim Johnson, M.D., spent more than a quarter-century reporting on medical breakthroughs and the latest clinical developments for ABC News. Over the past decade, during his tenure as chief medical editor for the network, Johnson became increasingly concerned about Americans having trouble receiving, and affording, health care. He began to realize that he, as well as most Americans, did not realize how costly and complicated the whole system had become and was troubled by how much inaccurate information permeated the airwaves. He decided to report on health care, just as he had on medical discoveries for years. Now, stepping away from his role as an impartial newsman, Johnson — who is also an ordained minister — offers his candid opinions for the first time in a new online book. In this excerpt from The Truth About Getting Sick in America, he tackles the question of whether the nation has a moral obligation to provide health care to everyone.

The big sermon

I am an ordained Protestant minister (I finished seminary before starting medical school), so you may not be too surprised if I think it is important to explore the moral issues related to health care. The most basic question, of course, is whether or not we have a moral obligation to provide health care for all our citizens.

Actually, polls show that most Americans feel we should not let people die on the streets, and that we should take care of them when they "really need it." The debates start when we try to discuss how to fulfill this obligation. Should we do it like we do now, with multiple levels of care, where those with money and/or good insurance can get attention more readily and earlier than those who don't have those resources? What's wrong with that as long as everyone eventually gets care? (As then-President George W. Bush once said, we have "access to care" because anyone can "just go to the emergency room.")

Well, there are several problems with this approach. One is economic. People without health insurance tend to delay getting care. When they finally get into the system, usually through the emergency room, their care will often be more complicated and costly than if they could have been treated at an earlier stage — or if their illness could have been prevented in the first place. The uninsured account for about one-fifth of ER visits in this country.

Take the example of an early stage pneumonia: Those of us with good insurance and ready access to some kind of primary care will get it treated with antibiotics — if it is caused by bacteria — but a person without insurance may delay to the point where they need to be admitted to the ICU with pulmonary failure, at which point their pneumonia may cost hundreds of thousands of dollars to treat.

Early care is key

But here's the point: If we are going to treat everyone eventually, when they get sick enough, why not provide basic insurance that would encourage people to get care earlier? We do have universal care in the sense that we usually don't let people die on the street. What we need is universal insurance coverage that provides preventive care and treatment at an earlier stage. I agree with those experts who point out that it is no accident that every other developed country has universal coverage and at significantly lower cost per person than the United States.

And we should never forget that those of us fortunate enough to have health insurance are, in fact, already helping to pay for those who don't have it — we just don't see it directly on our bills. Somebody has to pay, one way or another, for all the care provided in emergency rooms and public clinics for the uninsured. Most of that cost is paid by federal, state and local governments — and ultimately by taxpayers. Another way the uninsured are paid for is "cost shifting," in which hospitals charge higher prices to those with private insurance to help pay for the uninsured. So, again, if we are going to take care of the uninsured anyway (and pay for it), why not do it up front through direct insurance coverage, where the money spent could be more effective?

That's why I also favor mandates requiring everyone to buy health insurance — presuming it is priced fairly and that subsidies are available for those who truly cannot afford it. Again, if we can get over the emotional reaction of not liking "the government telling us what to do," insurance mandates make sense at several levels.

First, the basic idea of all insurance is to spread the risk as widely as possible. The more people paying into the insurance pool, the lower the cost for everyone. Second, it is also the fair thing to do. People who are young and healthy often complain about paying for something they don't need. But when they do get sick or have an accident and end up in the ER, they usually expect to be taken care of by society.

What about the "moral hazard" argument, which basically says that if you give people something for free or very cheaply, they will abuse the offer? A bowl of candy that is free, for example, will disappear more quickly than one where you have to pay by the piece. And some experts predict that is what will happen with universal health insurance coverage: People will abuse it by going to the doctor or clinic at the slightest twinge of pain. Clearly, this is a potential problem, which is why almost everyone agrees there has to be some sensible system of copays to prevent frivolous decisions. But aside from true hypochondriacs, my guess is that not many people will abuse the system for unnecessary major treatments or tests.

Insurance for all: a life-or-death issue

For me, the lack of good health insurance becomes a moral issue because we now have good data to show that people without insurance have a higher risk of premature death than those with it. A recent Harvard study suggests that as many as 45,000 people in this country die prematurely every year because they lack health insurance. How can people who call themselves "pro-life" live with that? I find it absolutely unacceptable as well as embarrassing that a country as rich as ours is the only developed country in the world without universal coverage!

Courtesy Hyperion Books

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