Dr. Katz: Universal care for goodness’ sake

We all know, and probably all periodically use the expression: for goodness’ sake! Perhaps it represents well the prevailing cynicisms of modern living that when we say “for goodness’ sake” these days, we don’t really mean doing something for the sake of its intrinsic goodness. Rather, we use “for goodness’ sake,” when we aren’t using less savory language, to vent exasperation. I will borrow both meanings to make a case for universal health care coverage, because, as a public health professional, I am more than a little exasperated with us, and because this is something we should do for the sake of goodness first and foremost.

Our protection by police is a public good. So, too the protection of our homes and forests by firefighters. And of course, so is the protection of our borders by the military. The U.S. military cannot possibly defend our borders for some of us without doing so for all of us; it is a public good.

Emergency medical care is a public good. The only alternative to that is a society where a financial test is applied before care is rendered to an 8-year-old hit by a car on the way to school. I hope and trust our common humanity recoils at the prospect. Assuming it does, then urgent and emergency medical care becomes a human right. We should treat it as such.

Once we do, there are two immediate implications. The first is that we are going to cover the costs of emergency care for all who need it one way or another, either rationally, or irrationally. The second is that universal coverage of emergency care without universal coverage of preventive care is a guarantee of more emergency care needed, at higher cost.

If the ethical positioning of emergency medical care as a human right is formally recognized, it permits us to plan accordingly. We could acknowledge that such care will be provided both to those who can pay for it, and those who cannot. This, in turn, allows us to determine in advance how best to distribute those costs. The answer is the obvious one, derived from the most relevant precedents: much the way we cover the costs of our military protection. Costs for a given year are estimated and projected, and all who can pay, do- in our taxes. We understand and apparently accept that the military protection our taxes cover will cover those with no means to pay any taxes, too. Such is the nature of public goods.

This approach does not, of course, spare us the need to pay for others along with ourselves. But it does distribute those costs widely, and in the most equitable manner possible. The alternative, applied uniquely to health care, is to make no advance plans for distributing the costs incurred by those unable to pay, and then directing those costs haphazardly after the fact. The results generally range from painfully irrational, to overtly tragic- as when a much-needed hospital serving an indigent community is put out of business.

Second are the implications of covering emergency medical care for all, without covering preventive care. Preventive care, from cancer screening to immunization, is to medicine what surveillance, treaties, NATO, the United Nations, and intelligence gathering are to the military. Viewed that way, the folly of leaving them out of the planning for public good is, I trust, self-evident. Imagine a military that never did anything at all until after we were attacked and imperiled, and ask yourself if that’s a satisfactory use of your tax dollars.

In case you are wondering, yes, we do have a source of the reliably evidence-based preventive services that contribute meaningfully, and cost-effectively, to the public good. The verdicts of the U.S. Preventive Services Task Force do not tell us everything we need to know, but we certainly need to know, and should cover, everything they tell us.

What stands in the way of progress and rationality is a toxic blend of cultural arrogance, misguided ideology, and selective blindness. The United States spends more on health care to achieve worse outcomes than many of our peer countries around the world, yet the arrogance of a “not invented here” mentality seems to preclude us from examining and adopting elements of best practices developed elsewhere. The contention that universal health care coverage is in any way more socialistic than universal military protection is not just ideological nonsense, but nonsense inconsistently applied. The failure to note the place for medical care among other public goods is selective, cultural blindness induced by the glare of ideology where epidemiology should be, and often by willful distractions, distortions, and overt deceptions.

There are many good reasons to preserve and improve the Affordable Care Act, and dollars figure among them. But first and foremost, we should do it for goodness’ sake.