Imagine Joe, head of a middle class household. He and his wife have a house with a mortgage. The house is too small and something always needs fixing. He has the usual bills and expenses, subscribes to a few streaming services, orders DoorDash a few times a week, takes the family on vacation once a year, and buys his coffee at Starbucks instead of brewing it at home. The kids are in public school, but aftercare, sports, and other extracurriculars eat into the budget. Money always seems tight, but that’s just life in our modern economy.
Joe’s doctor recommends a number of things. Maybe he needs a glucometer, or a GLP-1, or screening and lab tests, or just to eat healthier and go to the gym. Joe puts these off. The time commitment and money just make those things lower priorities for him..
Joe can afford the care by giving up something else he wants. He can cut back on food delivery, a streaming subscription, or vacation savings. Like anyone else, he has to choose between competing uses of his money. He just prefers spending some of his ordinary income on dinner delivered to his door.
Of course, as doctors, we want him to get the care. We think the screening is a better use of his resources than another streaming subscription. Helping people avoid preventable illness is part of the job. But Joe disagrees with the priorities of the physician and public health experts. How much freedom are we prepared to give him then?
I have repeatedly criticized the US healthcare system for routing routine care through third party payments. The standard objection I hear is that people who control their healthcare spending, like Joe, may buy less care than we think they should.
Milton Friedman captured this disconnect in Capitalism and Freedom:
“A major source of objection to a free economy is precisely that it…gives people what they want instead of what a particular group thinks they ought to want. Underlying most arguments against the free market is a lack of belief in freedom itself.”
The difficult part of patient choice is accepting those choices. As doctors, we see this all the time. Patients reject our advice for many reasons, financial and otherwise.
If someone is truly destitute, subsidies should ensure they don’t go hungry because they are rationing poverty-level wages. That’s exactly why we give cash-equivalent subsidies (SNAP) to the poor. This helps them get food without sacrificing their rent money.
Yet, outside of basic poverty, our society must decide who deserves a subsidy for basic medical care. There are stories of people cutting back on spending in other areas so they can afford their medications or doctor visits. That sounds harsh, but what are they cutting back on? Is it streaming services, Starbucks, vacations, or their kids’ school supplies? That distinction matters. Joe can pay for care by giving up something he wants.
It certainly sounds unfair to ask someone to cut back on their vacation savings so they can pay for medical treatment. However, if they don’t, we are asking American taxpayers to subsidize that person’s vacations. If someone wants to forego medical care so they can take a vacation, should we ask American taxpayers to pay for their medical care so they can take that vacation?
As Thomas Sowell eloquently states, “The first lesson of economics is scarcity: There is never enough of anything to fully satisfy all those who want it.” We routinely make room in our budgets for food, housing, and our children’s education by giving up other purchases. Even prosperity doesn’t eliminate this scarcity. That is part of life. And by making choices between those purchases, we are transmitting our values. If we value that vacation more than our own health, that is a choice.
Respecting Joe’s right to refuse care does not require taxpayers to spare him financial tradeoffs he can afford.
That should also make doctors examine our position in the transaction. A practice selling visits or screenings can benefit financially when patients purchase more of them. The people recommending a service may sincerely believe in it and earn their living providing it. Doctors can be genuinely doing good things for their patients while making a living at it. So can a personal trainer, nutritionist, or therapist. Someone selling healing crystals probably believes in their product as well.
“Preventive” does not exempt a service from scrutiny either. The shifting nature of these recommendations also shows there is room for personal preference. The case for screening should survive a discussion of its burdens, limitations, and alternatives. A patient who understands the discussion and still declines has not necessarily exposed a failure of communication. Sometimes he has simply made a decision, no different than ignoring the doctor’s advice to go to the gym or exchange the hamburger for a salad.
Unfortunately, that decision may eventually impose costs on others. Skipping screenings, ignoring minor issues, and poor self-care can impose later costs on an insurer or taxpayers. Shared financing creates a legitimate interest in encouraging beneficial care. But that interest needs limits, as deferring to that as the reason to compel resource redistribution is a slippery slope. Pooling some of those costs cannot give the payer unlimited authority over how people live.
Payers can try to incentivize good, healthy behavior, though. For example, OneHealth Nebraska, a network of independent practices, offers a self-funded health plan through UNICO and Auxiant for member physician groups with at least 20 enrolled employees. The plan offered financial benefits for primary care visits and laboratory testing. The arrangement gave employees a financial reason to do things their clinicians wanted them to do. Its published plan information also lists a $220-per-member wellness reward under its separate Medica fully insured offering. Reducing financial barriers to care, and even giving rewards for following that behavior may encourage patients to obtain beneficial care.
A private company offering incentives to reward healthy behavior is a different proposition than saying we must subsidize everyone’s healthcare so nobody needs to cancel Netflix to afford their antihypertensives. One is a decision made at a local level by a private company. The other is forceful redistribution of resources to subsidize lifestyle choices of people like Joe, who can afford care by giving up other purchases.
As an advocate of a freer healthcare system, I will admit that some beneficial care goes undone because people choose not to obtain it. That happens in any healthcare system in the world. If all care is subsidized so the wait times are long, many forego care rather than wait in line. The end result is no different than people foregoing care because they would rather not pay. We can work to reduce those numbers through access, better service, and persuasion. We cannot guarantee that everyone will make the choice we favor while leaving the choice with them.
Joe should definitely make his next appointment. He should do his screening tests. But if he wants to pay for his DoorDash instead, that’s his decision. The taxpayers just shouldn’t subsidize it.