The Finances of Medicine: An Escape from the Abyss?
Perhaps there is no issue more appropriate for the first of the year than the finances of medicine. The more developed nations are scurrying for solutions to deep economic problems that threaten the economic foundations of modern civilization. Excessive debt raises serious questions regarding productivity and the sustainability of growth in a mature culture. The problems are not simple nor do the solutions appear to be readily available. Political wrangling in this country appears to have dissolved consensus and paralyzed effective governmental response. Sitting front and center in the American economic concerns are the financing and expense of health care. Who does pay for it? Who should pay for it?
Philosophically, there is somewhat of a divide. Is healthcare a right or a responsibility? If it is a right, then presumably it becomes the responsibility of the government to provide for the protection and exercise of that right. Therefore, it becomes incumbent on the government to assure (if not insure) that every citizen has access to healthcare. The issues then become:
1. From where does this healthcare arise? Who provides it? If healthcare is a right, then presumably, high quality healthcare is intrinsic in that right. Who decides what is quality? Once quality is defined, who decides what constitutes sufficient quality to satisfy the right of the citizens?
2. How does this quality get paid for? Presumably, government will have some direct and potentially indirect expense—how does this imperative get funded? Where does it stand in the competing milieu of governmental responsibilities, such as national security, financial solvency, etc.?
If healthcare is a responsibility, then it is incumbent upon each citizen to do the utmost to seek and maintain his/her health so as to fulfill his/her role as a productive member of society. The challenges of such an approach are, on a personal level, no less daunting. What does one do when, despite every reasonable effort to maintain one’s health, underlying disease processes over which he had no control overtake him and present him with a health problem the solution for which is well beyond his financial means? Even if one were to say that the environmental hazards of various industries could be reasonably traced to individual episodes of disease, and therefore the industry should pick up the tab, what does one make of congenital and genetic diseases over which no one has control—and for which the treatment may require complex and expensive solutions? What is the response to trauma, infectious disease and countless other examples of serious conditions over which the individual had no control, and the treatment of which are beyond an honest working person’s financial means?
If the answer lies somewhere in between, we must certainly add to the list of questions, the thorny problem of collective responsibility. If the nation as a whole is paying, in part or in whole for individual health care, how does the system deal with people who choose to lead unhealthy lifestyles? Does one apply an extra tax to those who smoke? How about to those who are overweight? The former involves a clearly unhealthy choice. The latter may involve little or no unhealthy choices. Or it may involve choices that the person was unaware of being unhealthy. Or, more likely may represent a complex interaction of healthy and unhealthy choices, which involves a genetic proclivity that ostensibly unfairly affects one individual more than another.
The issues are complex and well beyond the scope of this brief message. However, one salient feature emerges from the virtual abyss which appears to describe modern healthcare delivery. Regardless of one’s philosophical or economic approach to the financing of healthcare, the role of prevention is one avenue that has been underexplored and underappreciated. A recent Robert Wood Johnson study estimates approximately $6 saved for every dollar spent on those prevention programs which have already been documented to be successful. Research findings are frequently enigmatic. However, one conclusion that has emerged from over a half a century of leading edge research at the Florida Heart Research Institute is that cardiovascular disease - the leading cause of death in the United States and increasingly throughout the world - is, to a large extent, a preventable disease. It is for this reason that FHRI engages in active, innovative and effective programs of education and prevention amongst the underserved, in Miami’s Hispanic community, and in the community’s workplaces. Perhaps we do not have answers to all of the challenging issues facing healthcare finance, but our research has taught us that prevention must be a part of the debate as our leaders seek to improve the health of the nation and wrangle with how to pay for it.
Dr. Paul Kurlansky, board certified cardiothoracic surgeon, Director of Research at the Florida Heart Research Institute, can be reached at (305) 674-3154 or email@example.com.