Even without a working crystal ball, it is safe to predict that health care will serve as battleground for ferocious debates throughout the 2012 election season. While the usual suspects -- cutting medical costs and keeping Medicare and Medicaid in business -- will take center stage, it will be the underlying question of entitlement that makes candidates stutter in front of the cameras. In a nutshell: it will be the question of who should be entitled to which part of the pie of health care dollars and ... drum roll ... who should be cut out.
On its face, this is a common "short blanket" budget problem. We need to cover more than we actually can, and no matter in which direction we pull, we are bound to leave cold injustice on the other side. Determining the side that loses "coverage" is where electoral votes will be gained or lost. One thing is clear: addressing the topic of entitlement directly on national television is, at the very least, a minefield. When the current administration tried to discuss the notion that, in some cases, care should not be rendered (i.e. the dollars should be spent elsewhere where they can do more good), headlines like "Obama's death squads" emerged as breaking news. Unfortunately, no one has come forward with a way to make such conversation safe, especially in the eyes of Main Street America.
So, this is where The Matrix, the movie, can offer interesting futuristic insight. As you may recall, the movie revolves around a world run by intelligent machines, who themselves still run on electricity. After depleting every other energy resource on the planet, the machines found that the human body could convert nutrients into heat and electricity pretty effectively. The machines then overpowered most of the human race and placed us all in underground farms to hibernate in a thought-provoking hallucinatory state, producing that needed electricity. The image of millions of people, lying in underground cocoons, quasi-alive as human batteries was enough to electrify very real box offices at the time.
Interestingly, this image sheds an uncomfortable light on the entitlement discussion. Even today, we can mechanically assist the human breathing function very well. Fast forward a decade or two, we will certainly be able to keep the blood flowing if the heart fails -- and somewhat compensate for the functions of failing organs. Under those circumstances, we could potentially secure much longer livelihood as we grow older and older. The age of 120 would become the norm, if we were willing to be kept alive in a (health plan-sponsored) cocoon and, importantly, if society were willing to pay for the cocoon farms. Now, personally, I would opt out. Even if I get cable and good A/C in my cocoon, that's not my idea of living. The question is -- if things are the same as they are today, who is expected to play the role of "the machines" and kick me off of the farm? In the absence of decisive leadership (a.k.a. political suicide) about lack of entitlement, we are heading into The Matrix. Yes, it will be in 3D and no, it will not have a happy ending.
So why is it that we get so angry when someone suggests that we should be entitled to less (e.g. not kept alive forever)? Arguably, it's a matter of distrust. We tend to question the decisions made by authorities, especially in such grave matters and especially when they pertain to our own good versus the good of the society. No matter how transparent the rules are, or how bipartisan the vote is, when it comes to me and my rights for health care, I don't want the machines (the government) to even consider kicking me out of my right for eternal life in the cocoon. I don't trust them. I don't trust the doctor on call either. He probably works for them. It's my decision, not theirs. But perhaps the moral solution is glaring us in the face. It's not OK for anyone to withhold care from me, but it is absolutely OK for me to decide to opt out. To not get it. To not BUY it. There is no doubt that our health care expenditures would drop if people would choose to not consume it. But why would they do that ?
Well, perhaps it will be for the same reason most of us don't buy a luxury car. It's certainly safer and more comfortable, but while we can probably gather the cash, we also have better uses for it. Everyday accounting makes us say no to things we really want. While there are numerous ways to introduce personal financial accountability into health care (e.g. high deductibles, personal premium hikes, indemnity insurance, HSAs, among others), there is another, unspoken major barrier to making health care a competitive, efficient buy-sell market: we, the consumers, don't know how to buy (health care).
In the absence of financial accountability and good understanding of our needs, we tend to buy more. Kids, loading carts in supermarkets, are a good example. If patients are to be given the right, the means and the accountability for buying health care services (and pointedly to opt out of what is likely not needed), we owe it to them to quickly make health care choices more understandable and transparent. Patients don't need to become doctors, but they should be able to effectively consult before they buy, so they can make decisions.
Like in any service industry, we need to be able to grade the vendors, rate the products, compare the offerings and talk to someone who can reassure us we have made the right decision. Improve the information on evidence-driven health websites, publish patient ratings of care providers, invest in the utility and credibility of nurse call centers and, importantly -- engage telehealth to bring health care professionals into patient's homes and workplaces, as their trusted councilors, their last checkpoint before tapping into the expensive health care system. Fortune-telling aside, if we empower patients with both the instrument to choose and acquire their care, and the way to do so responsibly -- we may see health care spending inching towards sanity. Lastly, since no one argues that patients are entitled to adjust their own consumption, we may not need to wait for our leaders to fall on their swords, to paradoxically make us a healthier nation.