Health Care is Expensive; So What?
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Leap, Edwin MD
Dr. Leap is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, and an op-ed columnist for the Greenville News. He welcomes comments about his observations, and readers may write to him at emn@lww.com and visit his web site and blog at
We like to pretend that we're above money or that it sullies our activities. We disavow financial connections, remind one another that our decisions aren't financial. I recently consulted a cardiologist for a possible cardiac catheterization. Not only does he need it, I said, he has insurance!
Don't tell me that. I don't want to know that, he replied.
In what other business (we are in business), do people act that way?
I've been thinking about money a lot lately. Unemployment is rising, and your stocks are in the toilet. My retirement has tanked. After medicine, I'll probably be looking for work as a mall cop.
Worse, we may be facing a dramatic restructuring of the health care system. That includes you. When people think of health care costs, they aren't ruminating on insurance executives, government inefficiency, nefarious trial attorneys, or unfair taxation. It's your bill that pops into their heads. The mantra: Health care is too expensive.
When I hear that, I think about the $200 rule my wife and I have. The entry fee for almost every activity in daily life is around $200. Take your stupid, snakebitten dog to the vet: $200. Fix that weird sound in the car: $200. All the kids get sick, need shots, need glasses: $200. Life starts at $200, but no one is worried they're charging me too much for vet care or car repairs.
Life is simply expensive: tuition, computers, mortgages, airline travel, airline travel with luggage. Someone is making money on all these activities of human life, but the one thing American politicians fret the most about is health care. The government isn't actively reforming legal care.
We need to remember that income doesn't represent greed, that wealth doesn't represent theft, that self-interest doesn't represent blind ambition. Income represents effort. It represents time spent in education, preparation, time away from your family. It represents your physical activity, your risk of injury and infection, your intellectual struggle to do the right thing. All of those are things worth compensation.
What do you do with this gross excess of wealth the world assumes you possess? Do you order caviar at pricey restaurants? Jet to Rio for Carnival? No, you're workers. I know you; I am you. You save for the future; you pay your mortgages (sucker!). You provide for yourself and your children. You take bologna sandwiches to eat at work. You don't ask for a bailout. You pay taxes. That money isn't wasted. It's earned, used, and reinfused into the economy. It's spent on the everyday business of life. It benefits our families, our charities, our governments. It allows us to avoid assistance from anyone else.
Despite our efforts, the necessity of what we do, the thrift and work ethic we employ, we are often reminded that health care in America is just too expensive. We doctors are breaking the bank. We hear it over and over: Sixteen percent of our GNP is devoted to health care.
But I want to ask a stunningly insensitive question: So what? If we heard that entertainment constituted 16 percent of the GNP, would we fret? Would we be cracking down on Hollywood or sports? Unlikely. We would say, At last, the good life.
I know we could be more efficient and that some costs are out of control. I know some can't afford care. The market could repair most of this, if unimpeded by deluded government. I also know that people all over the world envy our dysfunctional, allegedly broken, innovative system.
American health care is expensive because we believe that humans are valuable, that they deserve the latest science and the best medicine. It is expensive because excellent minds drive and practice it, and Americans want excellence. It is expensive because you physicians are those excellent minds, and you deserve to be well paid.
Our patients desire long lives, health, and function. And we have delivered it! The chaos of our system is probably the outgrowth of doing so much for so many so well. We aren't perfect, but the level of care available in any ED would stun anyone in a developing country. And we have probably applied our medicine more equitably than any other culture in history. Do you doubt that? When was the last time you turned away a badly injured drunk, addict, drug dealer, or criminal? You haven't, and you won't.
Having attained it all, Americans have discovered that the latest, greatest, and best is pricey. They want it on the cheap, or worse, they want to believe the lie that it can be free. This delusion allows them the financial discretion to spend on things other than medical bills or prescriptions.
I understand; my insurance is expensive. People who buy new trucks ask me for free samples. People who smoke two packs a day, smoke crack, and drink a case of beer every weekend say, I can't afford to see a dentist. Many could have insurance, but come to us saying, I can't afford it. So I came to you.
It's an issue of priority. I know patients who try their best who simply can't afford much of anything. That's one of the reasons the demon EMTALA was conjured up from the seventh circle of hell. EMTALA devalued medical care by making it seem free. In the process, it devalued each one of us.
EMTALA robs us every day. Our group collection rate is about 25 percent. EMTALA is the government moralizing about compensation and then dodging responsibility for it. It called for effort but didn't reward it, and so hospitals have closed, specialists have stopped taking call, transfers have become more difficult, and we work for free.
Now there is talk of reducing payments, whispers of provider fees and pay-to-play, of government control to lower costs. I'm not sure how much lower costs can fall than zero. That's the amount many of my patients pay me. I've paid-to-play for years through EMTALA.
And yet some dare to say that I'm one of the immoral rich, responsible for the problems of the economy. Physicians are the filthy rich? We who have spent our careers caring for the citizens of the country now are being told to give back. We have given back. We all deserve a tax holiday for the rest of our lives based on what we have already given back.
Who else would do what we do? Wrestle spitting, infected patients? Struggle to get care for a patient who isn't going to pay? Respond to the pandemic? Who is going to go back, day after day, and do as much as we do for free?
No one, that's who. So don't surrender your power, and don't underestimate your worth. Money is power; money is influence. Entertainers understand this clearly, and rush to attain as much of both as possible. So do lawyers, politicians, lobbyists, and everyone else. Don't ever stop striving to be recognized as a professional whose knowledge, skill, and compassion are extremely valuable. And feel no shame about your income. Money is simply a neutral, transferable reward for the immense, intangible quality of what each of you provide to the world.
And yet.
Money is a double-edged sword.
Have you ever met a rich physician who is miserable? Some physicians seem to grow angrier with every added dollar. The wealth they desired ultimately leaves them unhappy. It isn't just physicians. Many people have attained vast material riches only to realize they remain lonely, angry, dissatisfied, and frustrated.
But with physicians, I understand why. Money is a well-deserved reward for what we do. But money is also only a thing. What we do for humanity is so enormous and difficult that we cannot continue unless we see ourselves as part of a greater effort, the comforting and healing of fellow humans. All the money in the world will not give us the ability to work day after day and do well.
To be happy, we must use our time wisely to make what we need. We should honestly assess how much money we require and what we can do without. In so doing, we chart a path to freedom. We ought to stop living like doctors and start living wisely.
Be proud of your place and your calling. No money can substitute or compensate for the risks, sacrifices, and difficult situations you face. Be convinced of your own worth, insist on being treated as the valuable commodity you are. Act as if money is less important while knowing it necessary and appropriate. When someone tells you the care you provide should be free, ask what he'll give you for free.
Be proud of what you do, and never be ashamed of what you make. No one else is, not even politicians who make millions on consulting work. But don't ever believe that money will give you meaning or replace the time you spent away from your loved ones, doing things you hated, or living or working in a place you detested. It's a fine balance, but if you can find it, money will be your friend.
This editorial is an abridged version of a lecture Dr. Leap gave at the annual conference of the Indiana Chapter of the American College of Emergency Physicians. To read the lecture in its entirety, visit Dr. Leap's blog at edwinleap.com .
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