When you hear someone say, “health care is a right,” don’t immediately agree or argue. Ask: What is health care? What does the term ‘health care’ mean? What should health care include?
The word “health care” has been widely misused and abused, intentionally and unintentionally. Politicians, media, and even health care professionals have all used the terms “health care” and “health insurance” interchangeably.
Health insurance is not health care. Insurance, private and governmental, helps you pay for care, per contracts, with exclusions and denials that become obvious only after a claim is filed. Insurers do not provide care — health care professionals do. Insurers do not deny care; they deny payments to care. “Health care for all”, “single-payer health care”, and “universal health care” are health care payments, not health care itself. The Affordable Care Act (ACA), or “Obamacare” is not about health care but is rather a set of laws about health insurance. In fact, the ACA addresses almost nothing about the cost of health care (and indeed, its ability to plateau the cost of health insurance is questionable). A government can penalize its citizens for not having health insurance, but it cannot force its people to get health care (except in exceptional cases of rare public health situations).
All of the above said, insurance providers love the erroneous synonymous usage of the terms. They benefit greatly when their product (insurance) is equated to care itself. As a society, we have embraced the belief that health insurance is a quintessential element of health care. Patients believe that they can’t get care without insurance. Doctors are convinced that they cannot provide care without accepting insurance. And yet, most of us know someone who is insured but yet struggles to find a doctor. Most of us also know someone who is uninsured and yet succeeds in receiving all the care and tests available in a hospital. (Of course, such patients likely also receive enormous bills later; nonetheless, the standard, for now, is: care first, cash later.) Health insurance gives patients access to network providers, and it may also give them a comforting feeling that they’ll be helped in paying for their care. But a health insurance card does not guarantee care.
Another misuse of the term “health care” is in the realm of health information technology. The abundance of health information does not translate to actual care. Those that believe in futuristic artificial intelligence argue that robotic entities can provide care so long as they are programmed with a vast catalog of knowledge. But knowledge without experience creates confusion, not care. Electronic medical record developers boast that their EMR systems advance health care by enhancing documentation and communication. But physicians end up spending more time caring for records than for patients, laboriously drafting notes that talk a lot but tell little. And, absurdly, quality of care is judged and rated based on what was documented in the EMR. Bureaucrats believe that standard and high-quality care can only be provided when protocols are adhered to and compliance is recorded. “Best” or “worst” health care is defined by what is adequately transcribed and check-box documented.
So what is health care, exactly? Those that promote “health care as a right” use emergency and primary care as the foundation for their arguments: “Everyone should receive emergency care. Everyone should have primary care for general health, preventive care, and coordination of care.”
But in reality, health care is bigger than emergency or primary care. We have specialty care, sub-specialty care, advanced care, experimental care, end-of-life care, etc. And, even more broadly, health care is no longer just about sick care. It now includes wellness, holistic care, and even happiness. I find it hard to deny that vitamins, food and non-food supplements, and non-Western alternative treatments and therapies play vital roles in health care. (And, after all, we ask patients if they take those things on health history forms. I imagine vitamin and supplement makers would love for politicians to advocate “vitamins as a right,” or “supplements for everyone.”)
If we were to ask people what “health care” means to them, I bet we’d get all kinds of answers, most of which would sum up to: “things that make us feel better.” If I were writing a legal definition of health care, I, for one, would want health care to include a massage and a two-week vacation.
Ultimately, the term “health care” may seem self-explanatory but it is a complex and difficult-to-define term. It is one of those “I-know-it-when-I-see it” words – hard to know what it is, easy to know what it is not. “Health care” means different things to different people in different situations. Because of its complexity in meaning and simplicity in use, it is widely subjected to misuse and abuse in medicine, politics, economics, and, especially insurance financing.
As a physician who believes in direct primary care, I believe health care is a term comprising the work, emotion, and devotion that a caregiver provides to another person — a patient. As health and medical fields advance, they will continue to become complicated and convoluted; if we’re not careful, the true meaning of health care will continue to become diluted and confused.
It’s worth asking: what is “health care” to you?
Tuan Anh Duong, MD, is an internist practicing in San Francisco. He has great interests in direct primary care and medical economics.