Auto insurance is required by law in all states except New Hampshire, where one is obligated to provide evidence of funds to cover an at-fault accident, and Virginia, where one can pay an uninsured driver’s fee. Most Americans accept these laws, as few of us are interested in sharing the roads with drivers who cannot pay in the event of a collision. I am not aware of any pending Supreme Court cases challenging these mandates.
One could reasonably argue that, while liability insurance should be mandated, it is up to the individual whether or not they pay for coverage of their own vehicle. So, let’s imagine a world where auto insurance is not required. And, for the sake of argument, let’s put aside the question of liability. Those who are willing to pay for insurance will do so, and those who are unwilling, or unable, do not. Those that think of themselves as particularly safe drivers may figure that the cost of car insurance just isn’t worth it and simply take their chances.
In such a scenario, if I crash my own car and I do not have insurance, I get it towed to the shop (at my expense) and then, if I want my car back, I pay the price of the repair. If I refuse to pay the mechanic, he asks me to leave his shop and to figure out a way to get my non-functioning car off his lot. Seems pretty fair, right?
Let’s now imagine that same world. Except now, all mechanics are morally and ethically obligated to fix my car, regardless of whether or not I can pay. In fact, after training to become a mechanic, all mechanics took an oath that they would, to the best of their ability, fix any car that comes into the shop. Interactions with mechanics would not be typical business exchange. Rather, they would have an obligation to help everyone and the only really priority is to fix the car, at any cost. Because, in this imaginary world, every car is priceless.
Likewise, tow truck drivers are obligated to bring in broken-down or wrecked cars, from all points across the region, regardless of the owners ability to pay. In fact, some cars have to be brought in so quickly and over such great distance, that they are flown in by plane or helicopter. Of course, it isn’t just the mechanic working at the shop or the tow truck driver working on the streets. There is an entire team at the ready, including people to answer calls of distress, assistant mechanics, receptionists, managers, administrators, car part distributers and dozens of others. And it is not simply the mechanic’s time that costs money. Car parts can be quite expensive.
In this world, these car repair shops cannot close. Rather, a mechanic or one from his team have to be in the shop 24 hours per day, 365 days per year in case a car-in-need comes in at odd hours, weekends and holidays. The costs add up pretty quickly. And let’s imagine one last complication to this imaginary world where nobody is obligated to have car insurance: a once-in-a-century weather event creates an ice sheet on nearly every road in the, such that the accident rate skyrockets and that car repair shops around the country cannot keep up with the demand.
So, you ask, in this imaginary world, who is paying for my car repair if I cannot? The answer is pretty simple: you, the American people, are. If you have car insurance, you are paying extremely high rates to cover the cost of my crashed SUV. If you are paying out-of-pocket for your car repairs, your costs are astronomical. In fact, the cost of a repair is more than the value of the car and essentially unaffordable for all but the extremely wealthy.
Some may attempt to sign up for insurance only when they need it, say, after they have crashed their car. Private insurances, of course, will refuse because, if they didn’t, they would go out of business. And even if one could sign up for insurance after their accident, after costing insurance companies, car repair shops and other customers thousands of dollars, the forces that led to them being uninsured before the accident will still exist. And there will be no obligation for them to continue paying when their perceived need is gone.
In such a world, there are only two possible solutions that would make the system sustainable. Either everyone must have car insurance or the mechanics and tow truck drivers must refuse to fix cars if their owners cannot pay. As it turns out, in the real world, both apply. It would be crazy to imagine it any other way, right? And yet, the supreme court is about to decide if such a world, once again, becomes a reality. Only, it is not cars that are at stake. It is our health.
Back in the real world, I am not a mechanic. I am a physician. I care for children with cancer. I have the privilege of working at an institution, and in a country, where I can utilize life-saving therapies to which the majority of children with cancer around the world have no access. The therapies are costly. Yet, in my 16 years in pediatric oncology, I have never asked one of my patients' families, ‘Do you have insurance?’. Quite frankly, I don’t really care. Knowing a patient’s insurance status has no impact on how I treat them. If they have insurance, I recommend what I would recommend for my own child. If they don’t, I do the same. In both cases, my priority is to provide the best care possible, while also avoiding costly tests or therapies that do not improve care. If (or, more accurately, when) anyone in my family or I become ill or injured, I will hope for the same treatment from my doctor.
Clearly, the question about whether or not one has insurance is asked, typically at patient registration. Unfortunately, many patients are, indeed, uninsured. For some, it is because they simply cannot afford it and they must choose between having coverage and having food or shelter. There are others who are able to afford it, but do not view it as a priority. Some are well paid, often self-employed or employed by a small company that does not provide benefits. However, given the high price of insurance and the perceived low chances of getting a catastrophic illness, they may choose to gamble by refusing to purchase insurance.
And so we enter a vicious cycle. With no obligation to have insurance, many refuse to consider it until after they become ill. Therefore, the cost of insurance is even higher, making more and more people unwilling or unable to buy. And, as the percentage of those who do not have insurance increases, the costs of the actual medical care continue to climb.
Full disclosure: I am far from a policy expert, an economist or a law maker. But looking at this from the perspective of a physician, there is a simple truth that lies at the base of these discussions. We always hear about the debate over whether health care is a ‘privilege’ or a ‘right’. Some politicians and their constituents take somewhat of a “wild west” stance and feel that health care coverage should be available to those who can afford it, many of whom are still in favor of a safety net for the most needy. Others view universal access to health care as the only humane option in a country that is, in theory, wealthy enough to afford it.
But the truth is, it doesn’t matter what the politicians say or think. The fact is, health care is a right. I don’t say that as an opinion (although it is one that I share). I say it is a right because that is precisely how those who are providing the care view it. Regardless of how a politician, a policy maker, an economist, or even an individual patient, doctor or other healthcare worker may feel about how the national health system should function, you will not find doctors who are willing to turn away patients in a life-threatening situation due to the lack of insurance. In fact, it would be unlawful. And, of course, that is the way it should be.
So, unless we change the very nature of those who pursue careers in medicine and take away that moral and ethical obligation to care for all of those in need; unless we alter our interpretation of the Hippocratic oath; unless we turn the healthcare industry into a pure business exchange; unless we are willing to have the first responders check our wallets for proof of insurance before resuscitating us; unless we are willing to tell the ambulance drivers, paramedics, doctors and nurses, that they don’t have to be ready at all hours of the night just in case we need them; in short, unless we view our health, and the health of our children, like we view our cars, then there is no solution to the health care crisis without universal coverage, in some form.
Clearly, finding a solution is complex and difficult. It requires years of substantive debate and nuanced discussions with input from experts and well-meaning stakeholders. Unfortunately, this is not how problems are being approached at the highest levels of our government currently. Rather, we find ourselves in a situation where the future of healthcare is being shaped by partisan politics and grudges. The future of healthcare will not be decided by doctors, nurses or other healthcare workers. It will not be answered by policy makers, health care experts, public health workers or epidemiologists. And it won’t even be decided by voters through their elected officials as it was 10 years ago. In the end, it will be decided by the Supreme Court, a third of which was nominated by a leader whose main motivation is, first and foremost, to abolish the legacy of his predecessor, and which was appointed by lawmakers in the senate who still carry a grudge dating back to the initial passing of the ACA.
It does not take a policy expert to understand that there are hundreds of factors that influence how we will navigate this challenge for generations to come, that the ACA, in its current iteration, is far from perfect and that there is much work to be done to come to an acceptable solution to the health care crisis. However, looking at the issue through the lens of a health care provider, it is clear that the ACA case in the Supreme Court could make finding any future sustainable solution impossible. There is a reason that there currently is no viable option offered to replace the ACA by the current administration. It is the same reason that the rest of the developed world has implemented health care systems that provide universal coverage. It is because we are not cars and because, unlike care repair, health care, at its core, is a right. And there is no executive order, law or supreme court ruling that can change that.
Mark Fluchel
Mark Fluchel, M.D., is an associate professor of pediatric hematology-oncology at the University of Utah and Primary Children’s Hospital.