Our individualistic outlook toward health care shapes this situation. We prize our own health and are proud of taking steps to preserve it — think kombucha and yoga. As researchers have pointed out, being healthy is seen as a moral imperative. When others fall ill, we may blame their poor choices and lifestyles. Individuals with disabilities, smokers, people who struggle with drug abuse, overweight individuals and many others are subject to harsh societal criticism that fails to acknowledge the many barriers people face when they seek to improve their health.
This sense shapes policy: Rather than advocating for health care as a human right, policymakers have questioned why some Americans should be on the hook financially for the perceived poor choices of others. Conservatives have consistently argued that health care is a commodity to be purchased, and they eschewed visions of shared responsibility.
The global coronavirus pandemic has exposed the limits of such an individualistic approach — we realize now that we are only as healthy as the least healthy member of our community. If our uninsured neighbor becomes infected, our own health may be at stake.
In the United States, in the face of health policy crises, we have historically responded by carving out exemptions to our individualistic health-care system, rather than rethinking our overall approach. In the early 1960s, as hemodialysis for individuals in end-stage kidney failure became a possibility, communities were shocked by early attempts at rationing this technology. As dialysis machines were in short supply, ad hoc committees evaluated different patients and based on their perceived social value, determined who would be granted access to this lifesaving technology.
A 1962 exposé in Life, “They decide who lives and who dies” shocked the nation and led to broad discussions about the ethics of rationing care. Dialysis patients became fierce advocates for their care, with one even undergoing dialysis in a congressional committee room. Congress could not ignore this public debate and in 1972, the treatment of end-stage kidney failure, including the use of dialysis, became the first illness to be covered by federal funds.
One of the main reasons that politicians and the general public supported this plan to fund the treatment of kidney failure and particularly the very high costs of dialysis was that those suffering from kidney failure at the time were disproportionately young, white, employed and seen to have fallen sick through no fault of their own. This approach highlighted America’s view of health as an individual responsibility and the imperative for productivity. Those who had protected their health and still fell ill warranted a carveout.
Federal funding for the treatment of kidney disease was a welcome relief for many patients, families and health-care providers. But it also created new health policy problems. As the number of dialysis patients rapidly rose, their demographics changed, the population of sick people became older and sicker, and for-profit chains emerged to capitalize on the assured government funding for treating this condition. While policymakers solved the original rationing problem, they created new ones and ignored countless other flaws in the system.
Today, taxpayers essentially subsidize for-profit chains that provide care as cheaply as possible to turn a profit from the government funding they receive. Studies have shown that patients who received dialysis through these chains have higher death rates than those who received their care in nonprofit settings. Furthermore, these for-profit chains have high rates of using of expensive medications, some with unclear benefits. In 2015, the dialysis chain DeVita paid $450 million to settle allegations that it systematically wasted expensive drugs for kidney patients to bill the government for their cost.
The case of dialysis reveals how covering just one condition has led to a host of new and unintended consequences and further exacerbates the inconsistencies and incoherence of our health-care system. As comedian John Oliver incredulously noted, “it’s like your kidneys, and only your kidneys, are Canadian.”
And, over decades, we’ve done this sort of thing hundreds of times, producing an incoherent, inefficient system in every aspect of health care. Two other examples expose the breadth of this incoherence: Medicaid offers health-insurance coverage to low-income mothers up until six weeks postpartum. This cutoff point leaves at-risk moms who just had babies without access to care. Many experts today see this cutoff as being arbitrary, dangerous and fueling the maternal mortality crisis.
Similarly, the 2010 Affordable Care Act wisely mandated coverage of certain screening interventions (such as mammograms or colonoscopies) designed to encourage individuals to engage in preventive health care. Perversely, however, if a woman complains of having a lump in her breast, a mammogram is no longer considered “screening” and she would probably face an out-of-pocket cost. This is utterly inane — we should encourage rather than financially deter women from seeking care for breast lumps.
But our system is byzantine, impossible to understand and not designed to promote the best health outcomes.
The lesson is that, yes, the testing and treatment of covid-19 should be assured and funded. But we should not carve out an exemption only for this one disease. Not only would such an exemption leave us unprepared to deal with the next, inevitable pandemic, it might hurt patients who seek care in these difficult times only to find out that they do not have this illness but rather another condition that requires care — at a cost they can’t afford.
This crisis acutely demonstrates that public health is just that: public. We cannot individualize our nation’s health. Health is not simply an individual responsibility or a commodity to be purchased. It ripples throughout our communities, leaving all of us more vulnerable. Policymakers should not respond simply by carving out an exemption that covers covid-19 but rather by rethinking this individualistic mind-set, in recognition that healthy individuals make healthy communities, which produce a healthy nation.