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A popular sentiment regarding health care is that unlike other goods, we simply cannot tolerate differences in consumption based on income differences. Having a rich guy with a 90-inch plasma TV as compared to a poor guy suffering with a 36″ cathode-ray tube TV is not nearly as intolerable as the idea that if both a rich guy and a poor guy waltzed into an Emergency Room with a gunshot wound (OK, gurneyed in) and the rich guy was able to secure emergency surgery before the poor guy.

Health care is just different folks say. It is unethical to allow rich people to buy emergency surgeries before poor people can get them. To which I say:

  1. Even if in principle we agree with the above sentiment, in practice it is 100% impossible. What does it mean to say that a rich guy and a poor guy should have an equal ability to get treated for a gunshot wound? For one, poor people are more likely to get shot than rich people. So what does equal probability of treatment mean? It means that we draw a lotto ticket among all people who end up in the ER with a GSW. This means that sometimes the rich guy gets the treatment and not the poor guy. Do folks who wish for “equal treatment” really mean equal in this regard, or do they happen to think that “equal treatment” means that poor people are more likely to get it. I suspect they mean the latter even if they do not mean it.
  2. Even if in principle we agree with the above sentiment, in practice it is 100% impossible. If a poor person in rural Kansas is shot as compared to a rich person on the North Shore of Long Island, NY, do we think that each has an equal chance of even making it to the hospital? And when each ends up at the hospital, is the regional medical clinic in Kansas going to be providing the same quality of care as the world-class medical center on the North Shore? How do you propose we go about ensuring “equality” here?
  3. Rich people will always have access to better “health care” than poor people … no matter what mechanisms you put in place and even if we can magically transport poor people to the best hospitals the instant they fall ill. Why? Because there is no single good called “health care” and it is plain as day to understand that larger incomes enable folks to spend all kinds of money on goods and services that enhance the prospects of a healthier and longer life. Take a look at the data on mortality – rich people live a lot longer. People who complete a college degree live a lot longer. And there are a whole host of reasons why. Maybe the rich can afford health club memberships. Maybe the rich can afford nutritional supplements, more fresh vegetables in season, warmer clothes in winter, better antibacterial soaps and cleaners, cleaner homes, homes in cleaner cities, water purification systems, exercise gurus, workout videos and equipment, more musical instruments to help them relax, and so on for the myriad things that contribute to better health. Further, the rich are likely to be in safer jobs and to find themselves in healthier relationships. So what does it really mean when we say, “a rich guy and poor guy should be treated the same when both appear in the emergency room with a GSW?” The fact remains that each and every day this exact situation exists and we are perfectly happy to allow the rich folks to buy better emergency surgery (we just don’t call it emergency surgery!). How would you remedy this? Forbid the rich folks from using health clubs? Or put a special tax on health club memberships to the rich and use it to pay for health club memberships for the poor (why, then, do we have public parks and subsidized recreation facilities already?). Or do we have a TV police running around preventing poor people from spending any of their cash on televisions and iPods and the like just so that they can spend all of their free resources living a longer, yet more miserable, life?
  4. Here is how one gets removed from polite company. Explain why it is such a problem that a rich person would be able to buy their way to a more immediate gunshot wound treatment? You can imagine all kinds of reasonable arguments to allow this and even encourage it. If a poor person knows they cannot buy their way to better treatment, maybe that provides an incentive to put themselves in safer situations in the first place. Is that a bad thing? Or if a poor person sees rich folks buying better GSW treatment, perhaps that is an additional incentive to obtain higher education, higher skills, and better paying jobs? Or generally, what is different about buying a surgery than anything else? When I see some rich guy buy their way to some experimental cancer treatment that I know I will never be able to afford, does that drive me nuts? Should it?

The fact remains that even if we morally agreed that equal access to health care is a reasonable goal, it is not achievable. But it is not at all clear to me that there is moral unanimity here too.

5 Responses to “Rich and Poor Should Be Treated Equally in an Emergency Room”

  1. Trapper_John says:

    I haven’t heard the argument so much for “equal” healthcare as much as I’ve heard the desire for some minimum standard. Should people be turned away from the ER for a GSW or whatever malady they present with? Society has a difficult time answering anything but “NO!” to that question. Once you’ve pushed that cost onto the hospital and thus other patients/consumers, it’s really not that far to get to ACA.

    In my mind, the question is the line of demarcation between those who can afford to pay for what they want and those who are cast down among the plebeians to work within the government-sponsored system. Increasing access (i.e., demand) drives prices up, making it so fewer people get access to the “premium” healthcare. Ironically, this exacerbates the distance between rich and poor in terms of what that really means for how you live your life. Ultimately, the top 1% can’t be touched, but we can make it so those sitting at say the 75th percentile live much more like those in the 25th percentile than the 90th percentile.

  2. Harry says:

    I know and have known many medical doctors, some dear friends, one a dear uncle, and enough less close, but respected all. They do not distinguish between rich and poor, never have, when someone ill comes before them. The first thought is to do no harm, and the next is to decide what to do.

    Yes, there may be stories counter to my experience, but I have never, ever, encountered any doctor who has not thought of his patient first, period. I do not think that is dumb luck.

    Now, the other day I was talking to a friend who said he would not schedule a colonoscopy for a Wednesday at 10AM with his GI doc, because we both know he tees off at noon and might rush the examination.

    But this is not about rich or poor, it is about good scheduling.

  3. Todd Kuipers says:

    My responses to those that suggest level delivery for all users of medical services is best:
    – there are 2 things more important, the vast majority of the time, than medicine: food and shelter (including clothing) – making them much better talking points than consumer electronics. By the standard argument these same people should be heavily campaigning for food and shelter “insurance” and related services doled out by a bureaucratic team, to ensure that no-one receives better food or shelter than anyone else. If they perk up and think that rationing food and shelter are great ideas, trotting out Soviet food and shelter allocations, and wartime rationing, generally will get a thoughtful response.
    – in a transaction where money is not the deciding point for who gets the best/goes first – which I generally concede might be nice for argument’s sake – something else will replace money in that transaction. As it is in Canada, money is replaced by bureaucracy, influence and connections, meaning that the well connected – not necessarily the well heeled – often get preference over those without. Then the debate over whether an unaccountable bureaucrat (toss in cautionary stories about taxes, child services, et al) is necessarily better than a transparent market occurs.

    These can both be delivered politely, and if you’re not going to force your co-conversationalists to change their minds immediately, you can plant the seeds.

    • Harry says:

      Watch out, Todd. They might dream up a national “insurance” program for that, too. How about National Tort Insurance?
      Or college road trip insurance (covers beverages, gas, and major medical, including sex and disappointment counseling — free)?

      • Todd Kuipers says:

        Hey Harry – you’re right, there’s always an opportunity to drag the whole damn conversation into crazy town. If that happens, I just look around for another drink.

        That said, I have talked to actual humans that have advocated for coercion in something like experiential (e.g. college road trip) “insurance”, back-stopping bad decisions and prepaying for others. Nutty.

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