When it comes to health care coverage, House Speaker Paul Ryan says, "We're going to have a free market, and you buy what you want to buy," and if the people don't want it, "then they won't buy it." In this model of health care, the patient is consumer, and he must decide whether the goods and services he wants to protect his life are worth the cost.
But this is often impossible. And what Republicans, and many Democrats, forget to stress, is that in a totally free market health care system, you must be willing to let some patients die.
As an emergency medicine physician in a busy urban hospital, I have patients brought to me unconscious several times a day. Often, they are found down in the street by a good Samaritan who called 911 on their behalf. We are required to care for them, and most of these patients are grateful at my attempts to help them. More than once, however, such patients have regained consciousness furious. It wasn't that they didn't want to live — they were all simply upset at the costs their hospitalization incurred.
Last week I took care of a middle school teacher who was out jogging on a hot June day. Dehydrated, she lost consciousness when some tourists called an ambulance over to her. A month before that, I cared for a young man who passed out at his desk from a bleeding ulcer in his colon. His co-workers called 911 while he lay in a puddle of his own blood. And about one year ago, I cared for a 56-year-old patient who was found lying in the gutter at 3 a.m. A passerby called 911 thinking he was drunk. It turns out he had been hit on the head with an iron rod by muggers while on his way home from work as a waiter.
All three of them had ambulances called on their behalf by bystanders. All three of them, unconscious for some or all of their care, had no say in whether they would be treated. All three of them were saddled with gigantic medical bills that they had absolutely no say in.
Most dismaying for me as a physician is that after all of my attempts to apply my compassion and training to save their lives, all three of these patients told me some variant of: "Thanks for what you're doing, but I would rather that you hadn't." Even the man with the brain bleed, who certainly would have died without our immediate intervention, expressed dismay. In the neurology intensive care unit, with a bolt through his skull to measure the pressure around his brain, he told me that while he did not have health insurance, he did have life insurance. He said he would rather have died and his family gotten that money than have lived and burdened them with the several-hundred-thousand-dollar bill, and likely bankruptcy, he was now stuck with.
A believer in free-market medicine, Ryan has said about health care: "You get it if you want it. That's freedom." Yet being given services without your consent, and then getting saddled with the cost, is nothing like freedom.
Imagine Verizon sending you a bill for hundreds of thousands of dollars (roughly the cost of the medical care of the patient with the brain bleed who required an emergency neurosurgery and prolonged ICU stay) and then telling you, "We called you to offer you some extra services. You didn't answer the phone because you were in a coma, but we guessed that you'd want them, so we went ahead and added them on and charged you for them." Clearly you would be outraged.
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So why does this happen with health care? The answer is that we don't truly believe in free-market medicine. We know that in an empathetic and caring society, life is valued above all else, especially when the life in question is in the most helpless condition possible. Deep down inside, we all intuitively know that health care is not a free market, or else society would not allow me to routinely care for people when they are in no position to make decisions for themselves.
Republicans need to be honest with themselves and the public: If they want medicine to be truly free-market, then they have to be willing to let the next man or woman they find lying unconscious in the street remain there and die. In a truly free market, we cannot treat someone — and charge someone — without their consent and against their will. If we believe, however, that those lying there in their most vulnerable moments deserve a shot, then we need to push forward with the idea that health care, at its core, must be designed around a caring system that serves all people fairly.
Farzon A. Nahvi is an emergency medicine physician and an instructor of emergency medicine in New York City. © 2017 New York Times