Big Brother

On the eve of our national elections many are pondering the role of government in their lives.  We rely on our government for many of the basic necessities of life.  I am grateful to never have gone to bed at night worried that I could be bombed.  Likewise, the ability to turn on a tap and drink clean water is a privilege I take very seriously having lived for a year in Guatemala when younger.  The roads I travel, the electricity I use almost constantly, the schools my children attend are all a result of my citizenship in this great country of ours.  Additionally what makes our country great are the freedoms we are granted.  I am free to pursue whatever path of education and vocation I desire.  I am free to live wherever I want.  I can write such a blog as this and not worry about voicing my opinion.  That said, the delicate balance between taking care of its citizens and granting them freedom can at times be a tricky one to maintain.

Let me illustrate.  As a country the freedom of being able to drive wherever we want is tempered by speed limits, stop lights, qualifications of sobriety, seat belts and the mandate to have car insurance.  What may be viewed as protective laws by one could be construed as invasive antidemocratic abuses by another.  Such debates and concerns are also being raised in regards to the health of the population.

There are many social, moral and even economic reasons to improve the health of our citizenship.  A healthy society is a more productive society.  Disease and disability is a significant financial drain on the government. Achieving health reaches in to all areas of government.  More than delivering health care to the sick, health is fostered by reducing poverty, improving education and maintaining a safe water supply.  Do we as a society have a moral obligation to care for the sick?  What if it is illness that could have been prevented by healthier life styles?  Who bears the burden of such choices?  Those are not always easy questions to answer.

An obvious example is tobacco use.  By now, I would hope that we all know the dangers of smoking cigarettes.  I feel the government has done a good job of educating the public whether it be through packaging requirements, advertisements and to the youth in schools.  I, myself, spend a fair amount of time educating about its dangers as well as encouraging patients to quit and assisting them do so.  I have noticed, however, that the success of my efforts improves according to the price of a pack of cigarettes.  More heed my words when there is an economic reason to do so.  Is it right for our government to impose extra taxes on substances that degrade health?  Before all you nonsmokers cry out, "Yes!," think of proposals to tax sugared beverages.  How far can this be carried?

Is the health of our population the responsibility of society or the individual?  Certainly, as stated above, our society has a stake in our overall health.  Is it possible to legislate health?  How is that balanced with the freedom of choice?  Is it more important to safeguard the best interests of society or the freedoms we enjoy even if that means allowing the citizens to make choices may not be in the best interest of society?  There is a movement afoot that is shifting the personal responsibility of health from the individual to his or her physician.  In the past, we doctors, were viewed as personal healthy consultants.  Advice is given to patients for healthy living all the time but the consequences rested solely on the patient.  A diabetic patient who does not check blood sugars, does not follow a proper diet and takes the prescribed medication only sporadically, will suffer the consequences by developing the consequences of the disease.  Society, however, is coming to the understanding that the cost associated with a poorly controlled diabetic is born not only by the individual but also by the insurance agency and those who must pay the premiums.

These agencies are now shifting the cost of the disease to providers.  There is both a carrot and a stick approach.  We currently are rewarded when a high percentage of our patients achieve measures showing good diabetic control.  We lose that bonus when that number drops lower.  It is pretty clear that in the future, reimbursement from insurance agencies will be dependent upon these markers and that doctors will have to give money back to these agencies if the population of patients they care for are not doing well.

I have chosen the term insurance agency very carefully.  There are measures within "Obama Care," that encourage just what I have described.  However, before, we cast a disparaging vote in regards to the tyrannical oppression of our government, I think it is important to realize that these ideas are being espoused and acted upon with insurance companies as well. Regardless of the outcome of this week's election, such measures will be enacted.  I suspect that as a consequence, some patients will find it harder to find a doctor. Many physicians, tiring of the excessive regulations and now financial risk, are moving to non insurance models such as concierge medicine.  In such a model the patients are back to assuming the risk for their own health.  These are interesting times in which we live.  Your health is assuming a bigger audience than you ever imagined.  How we decide to cope with these issues as a society is likely to be debated for many years to come.