AMA Journal of Ethics^®

Case

Dr. Buccarelli is already behind schedule when he encounters his next patient, Mr. Van Ware. Mr. Van Ware is coming in for a follow-up appointment after a lingering, viral URI that finally resolved. He is politically engaged and has been following the Affordable Care Act legislation closely. His own insurance premiums have risen, and he asks what Dr. Buccarelli thinks of the individual mandate for health insurance.

“You think it’s fair that a young, healthy guy like me should be shouldering the bill for chronic care for the elderly?” Mr. Van Ware asks. Dr. Buccarelli replies in a general way that the current health system has its flaws and he is just happy that legislators are attempting to address the problems. Unsatisfied, Mr. Van Ware repeats his question about young people subsidizing older people’s expensive end-of-life care.

After a couple back-and-forths, in which Dr. Buccarelli politely explains that the ACA is 2,000 pages long and very complicated and that it will be years before the regulations are ironed out, Mr. Van Ware says, “Seriously, Doctor. You must know more about this new act than I do. Do you think the mandate that all of us, healthy or not, have to buy insurance is constitutional? Isn’t it socialism?”

Dr. Buccarelli considers all the answers he can offer Mr. Van Ware (who seems to have forgotten that, young healthy man that he is, he has had a serious URI for several weeks). Dr. Buccarelli feels his clinician’s role conflicting with his educator’s role and, meantime, his waiting room continues to fill.

Commentary

Dr. Buccarelli’s predicament is familiar to physicians who have spent any time in ambulatory clinical care. Falling behind schedule is annoying to patients and aggravating to doctors. Mr. Van Ware, with his resolving URI, ought to be an easy opportunity to catch up a little. Instead, patients often surprise us with unexpected symptoms or (as in this case) an urgent need to talk about current events.

Educating patients is an important part of practicing medicine. Aside from clinically relevant teaching that concerns the patient’s own condition, physicians have a broader role to share their unique perspective and knowledge with the public. Certainly, physicians have an inside track about health policy and health care reform. And yet, Mr. Van Ware may not be asking for Dr. Buccarelli’s opinion as much as he is grandstanding and debating an issue dear to his heart. He may be simply broadcasting his opinion to a captive audience (an opinion that is unlikely to change, no matter what Dr. Buccarelli says). Having attempted a polite diversion, Dr. Buccarelli can either address the issue or unequivocally notify the patient that the discussion is over. Giving Mr. Van Ware the benefit of the doubt, it may be that he is truly interested in his physician’s views. In that case, Dr. Buccarelli should have a few tight, informed comments to make about this important public policy issue directly related to medical practice.

Health insurance is a gamble, a bet. In a sense, you are betting that you willget sick or injured. If you “lose” the bet, you lose your wager (the insurance premium). If you “win” the bet, your payoff is that the cost of your medical care (or a very large part of it) is covered. Even young, healthy Mr. Van Ware can get hit by a dump truck running a stop sign later today and wind up being the recipient of several thousand dollars’ worth of medical care before the month is out. Groups like the Amish recognize health insurance as gambling and reject it. Interestingly, the ACA contains a religious exemption [1]. Although not specified in the law, many feel that Anabaptists (Amish, Mennonites, Hutterites) and Muslims might qualify under this provision [2].

Emergency medical care is already provided to the uninsured, and the costs are shared by others in society. When Mr. Van Ware gets hit by that dump truck, he will be taken to a hospital and treated, regardless of whether he has insurance. The Emergency Medical Treatment and Active Labor Act, EMTALA, passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA), requires hospitals to provide emergency care regardless of insurance coverage or ability to pay [3]. If Mr. Van Ware were given the choice to opt out of insurance coverage altogether, society would still share the cost of his care. Fortunately, we do not live in a society that allows uninsured people to die for lack of treatment. So, whether Mr. Van Ware realizes it or not, young, healthy, intact people already pay for the care of the old, sick, and injured. Costs are shifted to the government through taxes as well as higher insurance premiums across the board.

Universal coverage is more efficient and economical. In 2004, more than $40 billion in medical care to the uninsured was uncompensated [4]. The majority of this care was provided by hospitals. These losses are offset by government in the form of disproportionate share hospital (DSH) payments. Hospital care to the uninsured is fundamentally inefficient; it is emergency care, late in the course of an illness rather than preventive care earlier, when it is more effective. However one calculates the economic costs of caring for the uninsured (due to uncompensated, late, or forgone care), it is more than the cost of insuring them.

The current health care system is financially unsustainable. The American health care system has grown in unbridled fashion for years. Gaining control over this sprawling system is the first step in slowing and reversing cost escalation. Analysts may disagree about the best way to gain control. While not perfect, the ACA is expected to make a significant difference [5].

While physicians may want to have some prepared sound bites in response to common questions, they ought to have a deeper knowledge of some of the underlying issues. Clearly this issue is extraordinarily complex and the details can be mind-numbing. Still, there are some valuable resources that can be accessed easily through the Internet. The Henry J. Kaiser Family Foundation has prepared a number of excellent analyses of health care reform and financing issues [6, 7], the federal government has a useful website on the subject [8], and HealthCareAndYou.org is an authoritative site sponsored by several organizations, including AMA, AARP, AAFP, and ACP [9].

Finally, there is another issue that could arise in this situation. When people display strong opinions about social and political issues, there is often the potential for the discussion to become heated and personal. The doctor’s office is no exception. In this setting, however, there is a real concern about professionalism and the patient-doctor relationship. Physicians must continually be aware of their place in relation to the patient. Ordinarily, the patient is not the doctor’s buddy. In fact, preexisting friendships put considerable strain on a clinical relationship. When professional relationships get blurred with personal ties, both can suffer. The friendship can be strained when the patient is unhappy with the doctor’s decision. Equally problematic is the way in which professional decision making can be compromised with a patient-friend. While not as striking as when caring for family members, the medical decisions made for friends can be similarly distorted.

When political discussions take a bad turn in a friendship, people can just drift away, but what about a patient-doctor relationship? Suppose you hear what sounds like racial bias (or even a blatant racial slur) in a political diatribe [10]. Does it affect your attitude toward that patient and can you objectively provide care for that person any longer? What does it say about how someone views you when he or she feels comfortable saying hateful things to you? Of course, a patient who resists more subtle suggestions that political debates or speeches are off limits, may need to be told directly that the professional relationship cannot continue without a limit on that behavior.

When both parties understand their roles, many aspects of the relationship can be presumed and go unsaid. In some situations, however, the terms must be explicitly restated. When that happens, honesty, transparency, and clarity are required to keep things on track.