THE BLOG
04/01/2009 05:46 pm ET Updated Dec 06, 2017

Aaahh, Iiiiinnput!

In the 1986 movie "Short Circuit," a robot comes alive and immediately demands information about the world. While happily absorbing the Encyclopedia Britannica, he exclaims, "Aaahh, Iiiiiinnnput!! I feel the same way because numerous people provided input to a recent blogpost titled "Should fat people pay more?"
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The reason why I fervently seek input is not obvious. I am a physician trying to heal a critically ill patient. The name of this patient is M. Healthcare. As a result of my diagnostic work up, I found that the first step necessary to begin curing Healthcare is a consensus on what Healthcare should do. To acquire such agreement, we need to exchange ideas and opinions. "Should fat people pay more" [ has started that process. To complete this communication loop, I have written down below some of your comments and then follow these quotes with discourse.

One commenter wrote that it is "cheaper to let people smoke." Quite true, if the only financial concern is immediate cost of care. The "cheapest" solution - short term - to all medical problems is a bullet, which is much less expensive than Flomax or Lumnesta. But, humanitarian concerns aside, purely from the financial standpoint, we gain more money in the long run by having healthy productive people and by avoiding big expenses by paying for preventative medical care. Good medical care is expensive, but the NET is better than a bullet.

Someone asked, "Who is paying for my neighbor to go [repeatedly] to the doctor?" I believe the question was rhetorical. The Commenter knows that he is and you are and I am.

Profit and Health Insurance
Below is but a small sampling. Obviously this subject generated much heat. Let's eliminate the heat, anger, and blame game and discuss facts.
1) "I have yet to hear how the insurance industry has dramatically improved either medical care or cost management."
2) "What about the responsibility of the insurance companies to provide the best possible product?"
3) "My health should not make someone money."
Insurance companies do not exist for our - the patients' aka policyholders' - welfare: they exist (and thrive) for the benefit of their stockholders. The primary reason they sell [note that word, denoting commerce: profit and loss] insurance is to make money. We can play with the rules but they will always game the system to generate profit. The only real solution to this problem is to dissolve the problem: [Russ Ackoff's terminology] eliminate profit from health insurance. For Commenter #3, your health makes money for the insurance company but your being sick makes money for the health care providers. What we have now is an illnesstreatment system rather than healthcare system.
4) "I live in Europe now and that [government supported] is my health care."
5) "USA health insurance is double the cost of Canadian, and all is administrative overhead."
Many people tout other countries' systems - Canada, Taiwan, Great Britain and Japan to name a few - as superior to ours. They all have their good points but they have problems too. The Province of Ontario (Canada) spends 47% of its total budget on health care. Both Taiwan and England have doctor shortages that make ours pale in comparison. The NHS in England is trying to change its culture, especially its entitlement philosophy.

We are all looking for Mr. Quicksolve. We know our system is broken; we want a quick fix, now; and we look to others for an answer. Sorry, it won't work.

Bottom line: if we want a system that will actually fit us, we need to learn from others but create our own. While we are thinking about a new system, play what if: what if insurance companies or whoever pays for health care made money by our being healthy rather than our being sick??

"Fat people [or smokers] should pay more."
Several commenters objected. A 200-pound man who is 6'5" and a hemophiliac asked, "are you going to make me pay more?" Another wrote, "obesity is indicative of psychological illness and thus we are punishing the victim." There are several issues here.
The consequences of personal responsibility can only be applied differentially when individuals have a choice. The tall man who is a bleeder; my son with thyroid disease; my neighbor with breast cancer; or me with my pulmonary embolus: we did not choose these things, cannot be held responsible, and should not pay more.
One can take the position, as above, that all aberrant behaviors are indicative of illness but where do you draw the line: obesity...smoking...illicit drugs...embezzlement...domestic violence...arson...rape...murder...genocide? Again, let's openly discuss this but we need to draw a line somewhere.
There is no rule or system that will work for every person in every circumstance all the time. We have to make decisions in the best interests of the most people while protecting those who cannot speak for themselves.

Personal responsibility
One person commented that masters protected the health of their slaves so they could work. The analogy is well drawn. As you increase the protection by [and therefore the power of] the master, you decrease the freedom of the slave. In other words, any level of personal freedom, anything less than total servitude or chattel slavery, comes with some personal responsibility. This in turn means that bad things can happen to us either from bad choices or simple happenstance.

A number of writers used the term "sin tax." I recommend that we avoid assigning value judgments and call linking what we do with what we pay a choice charge.

Humans are imperfect.
"We are imperfect creatures and should come to grips with it." This simple statement is quite important for you and me, looking both at ourselves and at the providers. A large part of our health problems is self-generated. Many obese people (I did NOT write all), most smokers, and all who take drugs inappropriately are causing their own health problems by their choices. At present, we all pay for these health issues. We need to discuss and openly decide how we want the system to handle it.

Providers too are human yet we expect them to be perfect and never make a mistake. That is as logical as expecting obesity, smoking and illicit drugs to disappear. Ain't gonna' happen any time soon. We need to stop blaming the nurses and doctors when adverse outcomes inevitably occur. We need to eliminate a medical malpractice [aka vengeance] system that fails to protect or assist us. We need to accept the providers' imperfections and demand that the healthcare system have safety mechanisms that protect us from their humanness.

"I want universal health care."
Several commenters either wrote this specifically or implied it. Let me write something that you should all agree with. Before we decide anything, let's be clear what we are talking about and what the consequences will be of our decision.
"Universal health care" means different things to different people. It has different implications depending on how it is constituted. For instance, does "universal" include illegal aliens or visitors from foreign countries (British NHS does not cover them)? If universal health care saves money, are we prepared to put more than a million Americans out of work?
I am NOT opposed to "universal health care." I am opposed to buying a black box whose contents we do not know.

Thank you for all your iiiiinnput. Let's keep this up.