Healthcare, right or privilege?

I know, this can be a touchy subject and I am not going to pretend to have the answer, but I believe it is important that we have this conversation as we work through the issues currently facing healthcare in the United States. I also am not going to pretend to be an expert, certainly not on healthcare entirely, but I do have some experience, especially in emergency medical services.

Most people are unaware and uninformed of the experiences of emergency medical services providers. Most assume they are filled with cardiac arrests, severe respiratory distress, critical trauma, heart attacks, strokes, and other “true” emergencies and while this is partially correct, would it surprise you to learn that a significant portion of 911 calls for service are not necessarily “true” emergencies, but instead people that lack resources such as housing, food, transportation, prescription refill, behavioral health, or primary care? People routinely utilize the 911 system for: a hot meal and a bed for the night; the ambulance ride to the hospital because they don’t have their own car, a family member or friend that can take them, or money for a cab or public transit; prescription refill because they have run out of their medication and they can’t get into their primary care physician (if they even have one) for several weeks; and, their limited behavioral health benefits have run out (if they had them at all). Sometimes, they call 911 because they assume if they arrive by ambulance, they won’t have to wait in the emergency department waiting room.

I bring this up in the context of the question of healthcare being a right or privilege because from an emergency medical services perspective, due to EMTALA (and basic principles of humanity), access to emergency healthcare is a right. Emergency medical providers must treat all who call upon their services without prejudice, whether or not they are insured or have the ability to pay. In most communities, EMS protocols don’t allow them to transport the patient anywhere but the hospital and they seldom, if ever, permit EMTs and paramedics to treat and release. This means that most people that call 911, whether they are having an emergency or not, whether they can pay or not, are going to the hospital by ambulance.

What we know about healthcare is that emergency is the most expensive form of services. Primary and preventative care is significantly less expensive and if used, greatly improves health outcomes and thereby reduces morbidity and complications. If we treat services such as primary care, preventative care, dental care, behavioral health, eye care, pain management, nutrition, chronic disease management, and programs that address the social determinants of health as a privilege, we all pay for the over-utilization of emergency medical services for two reasons. One, people will be sicker because they don’t have access to primary and preventative care thereby utilizing emergency services in their place or waiting until they are so sick, they actually experience an emergency. Two, all services will be more expensive because somebody has to pay the bill. Nothing is free.

The cost of doing nothing is exorbitant. Untreated behavioral health results in greater crime rates, jail and law enforcement costs, increases in drug and alcohol abuse, homelessness, and more. Not addressing social determinants of health such as housing, food, transportation, nutrition, and education results in poorer health, an increase in medical costs, lost productivity, and more. Not only is refusing access to quality human services due to a lack of ability to pay inhumane, it is fiscally irresponsible. What are your thoughts? If it isn’t a right and it is a privilege, when do we say “no” and how?