Sense of Entitlement Likely To Metastasize by Edwin Leap MD

Obamacare has been ruled constitutional by the Supreme Court, those esteemed individuals we consider sages when they agree with us and tyrants when they don’t. The decision has rendered supporters of the law positively apoplectic, even rapturous. Detractors have been lying in fetal positions taking antacids and trying to figure out how it all happened. Either way, for now it’s a done deal. The politics of the matter remain to be seen.

While not a supporter of the legislation, I am man enough to concede and say that I hope it works. I admit that there are a couple of provisions that are (at least temporarily) merciful in its pages. Among them, coverage for preexisting conditions; a thing that could be very useful for my diabetic teen as he grows older. In addition, there’s the ability to keep children on their parents’ insurance until age 25. Withunemployment soaring even among undergraduate and graduate degree holders, mom and dad may have the only insurance available for the kids as they ply their advanced degrees and theses by serving fries and burgers.

The problem I have with the Affordable Care Act (well, one of the problems I have) is that it presumes a certain amount of responsibility among the populace and due vigilance in the government (not particularly common on either part.)

What I mean is, the Affordable Care Act requires that individuals purchase health insurance or face a fine. The same goes for businesses. Of course, businesses are easy to fine. But individuals? Less so. And really, if the government is unwilling to deport illegal aliens in custody for crimes, or imprison multiple offender drunk drivers with suspended licenses, do we really think they’ll take a person to the mat if they neither purchase insurance nor pay the penalty for failing to do so? Seems unlikely to me. Thus, individuals will not add to the fund from which they’ll draw deeply when they are sick themselves, and finally get insurance (like a death-bed baptism).

The other problem is not about fines or rules, but about lifestyles and attitudes. Hospitals have all too many patients with no sense of accountability, who ‘take’ as a way of life. Not a majority, mind you, but a powerful minority have developed an incredible alacrity for navigating hand-outs, programs, criminal courts, government checks and assorted entitlement programs. This isn’t a screed against the poor, but a shot at the manipulative. All too often they come to hospitals only for pain or anxiety medicine or work excuses. Or for manufactured drama on weekend nights. Frequently, they come to add weight to their somewhat spurious disability applications for things like ‘I can’t keep a job,’ and ‘I get angry a lot.’ (Yes, we actually heard those from healthy young men seeking disability checks.)

These persons, soon to be eligible for insurance, are superb at obtaining food, medicine, money, drugs and influence at the expense of others. They understand how to use state and federal programs with maximal efficiency. And they know that speaking loudly, calling out for ‘patient care representatives’ and filling out negative satisfaction surveys will generally, in most large facilities, get them their snacks, drinks, pain medicine and excuses. The amount of money hospitals spend tracking down frankly false complaints, for pain prescriptions alone, is staggering.

To understand the depth of this problem, just ‘ask a nurse,’ and you’ll get an earful about the awful treatment they endure, the way nurses and other care providers struggle to care for their own kids and make ends meet only to be told by a fully capable adult, ‘I need you to give me my prescription, since I don’t have any money.’ This as their i-Phone and cigarettes spill out of their pockets, and their drug screen lights up for marijuana, cocaine, opioid pain medications and the now ubiquitous Methamphetamine. (All of which they can magically afford).

Here’s my point. If anyone thinks that providing a means to insurance for everyone will make all people better or healthier, they’re wrong. While it will likely benefit many, the patients I’m discussing won’t work on their diets, smoking, drinking, Meth use or their serial paternity. All they’ll understand is that there’s one more way to get things they want without contributing to the solution.

Ironically, in this way the ACA might inadvertently cause entitlement to metastasize even more widely than it already has. I hope I’m wrong. But experience, in the real world, with real human beings, suggests I’m not. I suppose only time will tell.

Dr. Leap’s Blog can be found here:

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  8 comments for “Sense of Entitlement Likely To Metastasize by Edwin Leap MD

  1. July 13, 2012 at 4:32 pm

    Your comments about people riding the system hits close to home. I work for a government agency whose name will go unmentioned. Recently one of our patients became violent and had to be taken down and put in cuffs and belts. He filed a complaint that we were too rough even though the only thing hurt was his pride. Five people were taken off the ward pending investigation. That was almost two months ago. Meanwhile the patient in question was discharged for being a fugitive felon. Yet we continue working short-staffed and getting beat up by mandatory overtime. Any private sector place would have questioned those involved, gone to lunch, reviewed the tapes and come to a decision the following day. Because of government bureaucracy, the investigation is still pending.
    We get a fair amount of admissions for people with “depression” who turn out to be lamming it from the cops or from their drug dealers. It’s enough to turn me into a god-damned Republican! On the other hand I realize these folks are small-time chiselers compared to the agribusinesses who get paid farm subsidies, the oil companies who get tax breaks despite making record profits, etc.
    We take care of an under-served population and I would rather take care of bums than yuppies. I am honored to take care of those who are down and out, those who are suffering PTSD from the wars, those who are legitimately schizophrenic or psychotic or genuinely want to get off of drugs or alcohol. Just the ones there to put up at Uncle Sugar’s Hotel are an annoying minority. They waste a lot of time. I am not very confident in a bureaucratic behemoth like our government to respond appropriately. They are great at micro-managing, but don’t seem to get the big picture.
    Believe people should have access to basic health care. Used to work a lot in the ICU with ventilator patients. Saw a lot of people languish for weeks on every inotrope in the pharmacopia who still died anyway, but the family threatened to sue if we didn’t do everything. Who picked up the bill in excess of $250,000? Believe any kind of universal healthcare is going to involve a lot of tough love and not-so-subtle encouragements for people to change their life-styles. This will be easier said than done.

  2. July 11, 2012 at 11:55 am

    The basic question remains: Should a society, insofar as possible, provide health care (not insurance) to all its members on as equitable a basis as possible? That’s a test which American “health care” continues to fail, creating worse health, wasted resources, and major stress. The Obama administration tried for a more comprehensive approach to the problem, but the other party, more intent on November 2010 and November 2012, did everything it could to foil him. The healthcare act was the result, not the goal. And it can be amended over the years, like any other major legislation, as the needs occur.

    It’s one thing to identify the Bad People who abuse the existing system. It’s another to come up with answers to the leading question above. Obviously, our existing healthcare nonsystem does little to prevent abuse.

    In my opinion, getting the profit motive out of health care as much as possible should be the ultimate goal. We did that with fire departments. The lazy/irresponsible/nontaxpaying meth head can still expect the fire department to arrive if his hovel catches fire, despite his Unworthiness. Maybe we should just shoot him?

    I think one of the biggest drags on health care is the need for practitioners to simultaneously be business managers. Instead of the hours spent with business consultants, I’d like my doc to spend that time reading a journal, sharing ideas with peers, or even playing with his kids.

    It would be helpful if the other party would come up with some rational/comprehensive/health-related ideas of its own. The tired old ideas of selling insurance across state borders and tort reform have some merit, but have never been demonstrated to make much difference, even in theory. And they can’t deal with the basic question, which remains: Are we, in part through our governments, our brothers’ keepers? Or did the universe mean for health problems to be just another source of profit for some?

  3. July 7, 2012 at 11:54 am

    Thank you for bringing the issue of entitlement in health care to the top of the pond for observation. With all of the problems in health care, this is one issue which often never makes it into the spotlight.

    I am one of those people who believe that like other countries, the United States should be providing a basic level of care to everyone. Not liver transplants, but basic preventive care that keeps people out of emergency rooms and hospitals. Other countries do this very well. No, I don’t want to hear about that being socialized medicine. It is.

    But my belief is that we already have socialized medicine — administered by the insurance companies. We already have the government telling us what will be paid for and what will not with Medicare and Medicaid. The insurance companies tell the rest of us what will be paid for and what won’t.

    How is this any different than nationalized care, except that the control is balkanized.

    I would much rather deal with one yes/no controller than three, or actually in reality, hundreds, since there are so many insurance companies.

    One of our clinic’s patients had a claim denied for four months. Each month the denial package (I say package because it was a list of fine print denial codes that extended for three or four pages) was delivered to the clinic at great waste of postage and paper. Finally, after about four months, the insurance company paid the claim.

    The next month the clinic got a check in the mail for 10 cents — interest on the unpaid claim.

    Now tell me how this is any better than nationalized medicine?

    Entitlement takes many forms. There are many patients who feel they deserve free care and get rude about it. But the flip side is the entitlement of the payment gatekeepers, gatekeepers who from my perspective are a lot ruder and more raucous about physician “fraud” than any patient has ever been about demanding free care. The witch hunt for fraudulent physicians does horrendous damage to the majority of those who practice honestly, but nobody labels the witch hunters entitled.

    I would say it’s more of a question of what kinds of entitlements — and there are many — that will lead to nationalized medicine. And I strongly suspect that when it comes, no one will attribute its existence to entitlements of the gatekeepers instead of the individual patients who demand free care.

    • Pat
      July 7, 2012 at 12:25 pm

      Diane, (1)how would you expect the witch-hunting of doctors to fare under a completely nationalized system?

      (2) And why not include liver transplants in your version of entitlement? On what basis do you limit anything?

      (3) Do you really believe basic preventive care keeps people out of the ER? In my experience, unlimited access to ER’s is its own incentive. WOuld you likewise limit ER access?

      • July 7, 2012 at 3:58 pm

        All good questions, Pat.

        (1) I wouldn’t expect the witch hunting to disappear, but at least there might be fewer entitled entities going after physicians trying to do their job.

        (2) The decision of what to include in basic health care is a very difficult one. Years ago Oregon Medicaid decided it was more productive to provide prenatal care for hundreds of women than fund one child’s liver transplant. Because insurance companies pay for liver transplants, this was deemed an unfair decision aimed at poor people. Oregon was willing to look at the tough decisions, but it created such an uproar, I believe Oregon gave up trying, at least at that time.

        In other countries, people can purchase insurance to cover what the basic insurance does not cover. In many ways, not a lot different from the Medigap policies available here. Or consider that Medicaid already provides secondary insurance to Medicare patients.

        But at some point, we are going to have to make some tough decisions no matter the uproar.

        (3) Our clinic opens on Saturday afternoon specifically to offer our patients an alternative to the ER, and it works. But we are in a rural area and the nearest ER (besides our local one) is 40 miles away. If we had enough staff, we would open on Sundays as well.

        I have seen ERs in a metropolitan area of our state triage patients, sending the non-emergency patients to an associated clinic. The problem with our local ER is that there is no triaging, and no walk-in local clinic available around the clock.

        Could we shed enough of the government regulations creating the unlimited access to ERs to stem the flow of traffic. I think it could be done, but the public outcry may be right up there with not paying for liver transplants.

        • July 8, 2012 at 4:13 pm

          I think the only way to address wasteful ER usage would be a combo of major, radical tort reform – sovereign immunity? – and eforming the VERY harmful EMTALA statutes.

          Glad you brought up Oregon! That example showcased why I oppose nearly all federal health care involvement. Recall that when Oregon came up with a Medicaid “triage” list, it was the Clinton Administration that overruled them no the basis of unfairness. I’m not being partisan, but arguing that a central health care authority will always take away the flexibility needed to better address the concerns of a given local population.

          • July 9, 2012 at 11:02 am

            No argument with the premise that a central health care authority will always take away the flexibility to respond to individual health care needs.

            But at some level, I feel if there were fewer authorities pulling everyone in opposite directions, it would be easier to identify the biggest problems and address them in some sort of coordinated, focused manner.

            The problems are the same, but perhaps more identifiable, and therefore slightly more amenable to change.

  4. Pat
    July 7, 2012 at 8:19 am

    You’re not wrong, as your excellent piece demonstrates. Where I take issue is how, trying to have a good attitude about the inevitable, you are trapped like so many other good people: there is no appropriate federal role in the daily delivery of care, even for preexisting conditions or to further a parent’s love. Good friends and loved ones continue to express to me support for the ACA provisions regarding “non-discrimination” and covering adult children, unmindful of the deadly law of unintended consequences. As the dwindling number of insurance companies charge higher and higher prices, these two provisions will worsen the acceleration toward fully nationalized care. Inevitable now, in any case.

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