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Interviews
Brent James, M.D.
Vice President for Medical Research Intermountain Healthcare
Interviewer
You’ve mentioned that much of the cost of our present medical system can be attributed to the rule of rescue. What is that rule?
Brent James
The rule of rescue is first described by a fellow named Johnson twenty years ago. It's the idea that as a human being we respond much more readily with someone with whom we have an emotional relationship. An emotional relationship all that's necessary is a name and a face. Yeah, then you feel almost this compulsion to help a real human. It's the difference between a story and a statistic. It's the child down the well. Back in the old days we had those big oil wells down in Texas. When the child falls down it, adult humans will risk dozens of adult lives, lose some, and still count it as a success if they can somehow rescue that child. It's the whales trapped in the ice a few years ago. It's that dog on the abandoned fishing boat, you see. That's the rule of rescue.
Interviewer
So is it this notion that because we feel compelled toward the individual we'll go to a heroic extent?
Brent James
The rule of rescue is the idea that when we establish a relationship with someone we'll go to heroic means, spare no expense, to help even though the things we may do have very little positive impact, sometimes not at all. It's the idea of do something she's dying. We're almost compelled to act you see. That's the rule of rescue. It trumps reason. It certainly trumps statistics. It becomes the political mandate.
Interviewer
So we start acting now out of what we can do instead of what we should do?
Brent James
The rule of rescue really means that we do anything that might work instead of carefully considering things that do work. It also unbalances us a bit. You see the real problem with healthcare... any treatment that is powerful enough to heal, can also harm. As any good physician understands, you're always balancing risks. How much will this treatment potentially help my patient versus how much harm might it do? And under the rule of rescue we tend to ignore the potential harm. We only see that possible good right? So it means spare no expense, pull out all of the stops. Quality means if it might work let’s do it, and it turns out that is a really poor definition of quality--that very frequently it leads us to put patients actively in harm’s way to do damage with the aim of doing good. It's not just the fact that it massively increases the cost of healthcare which limits access; it's also the fact that sometimes it actually harms patients on average. I mean it does more harm than it helps.
Interviewer
It seems to me that if I get treated, that's a helpful thing. It seems a foreign concept that treatment could hurt you. How is that?
Brent James
You know we first really published back at The Institute of Medicine in 1999 a famous report called “To Err is Human”. Within that report we did a careful evidence review. It turns out there are many good published articles in the medical literature documenting this fact. We were very conservative. We took some of the lowest estimates with harm associated with care, but that's where we estimated that somewhere between about 44,000 and 98,000 Americans die each year from preventable injuries associated with care delivery just in hospitals--preventable injuries. That makes American hospitals somewhere between the fourth and sixth most common cause of death on the planet. More deaths are from preventable injuries at hospitals than from the entire AIDS epidemic. At its peak, AIDS only killed about 16,000 people per year, at its peak, more deaths from hospitals than from all breast cancer--only about 35,000 deaths per year from breast cancer. It means that American hospitals are a major public health issue in terms of the harm that results and it comes out of this philosophy, this idea of "I've got to do something!" We got to try it if it might work you see; so the rule of rescue kind of imbalances you. Yeah, you focus so tightly on the good that might occur by some wild chance that you ignore the harm that does occur.
Interviewer
It seems like we have a health care system that is great at critical care, but we're not so good at the basic primary care.
Brent James
The big mistake that we make is that we equate health to healthcare and they're not the same. The best evidence that we have shows that about 40% of a person's total health comes from your behaviors, your own personal choices. The three big challenges to your health, by far the biggest impact: tobacco #1. #2 is alcohol and other recreational drugs. And #3 - Doctor Joe Andrade at the University of Utah's Department of Bioengineering has a great name for it--he calls it Movement Deficit Disorder, MDD, aka obesity. I much prefer to say that I suffer from MDD than I'm just too dang fat. It causes diabetes mellitus, a long list of other major chronic conditions. Well those three account for about 40% of your total health and a few other smaller ones. About 30% of your total health depends upon how wise you were in selecting your parent’s genetics. We have very little we can offer to patients around that today.
About 20% is public health, particularly control of epidemic infectious disease through sanitation and immunization. About 20% of your life span comes from that. Only about 10% of your total health comes from the healthcare delivery system, which leads you to question why it is that we're spending 16% of the country's entire wealth per year, 16% of the gross domestic product, 2.2 trillion, 2.2 million, million dollars per year on that 10%. The only way that you can understand it is the rule of rescue--this almost unopposable force that we have to do something to help someone's that's suffering or perhaps facing death you see.
Now there is a second factor that plays a role too, we call it "high touch." You know back before 1900 the caring professions had almost no impact on a person's actual health. We were just as likely to kill as to heal, but still healing professions played a central role in human society. The reason was the caring part. Yeah, it was a shoulder to lean on, it was a listening ear. It was someone who could tell you what came next. If there were any healing involved it was mainly spiritual healing; achieving balance, a sense of closure, coming to peace with your life-- that’s what we supplied. In the last 100 years as the healing professions have moved further and further into technical medicine, into curing, in some real sense we've lost some of that. But the interesting thing is to patients, it's still centrally important. When you carefully ask patients it turns out that they value their relationship with their physicians and nurses more than they value their health outcomes--we call it "high touch." Well when you combine those two things--the rule of rescue and high touch, it goes a long way to explain how we spend money for healthcare in the United States.
Interviewer
So what should we be spending our money on?
Brent James
There's a famous person within this field, Dr. W. Edwards Deming defined what's called quality improvement theory of process management theory... a major success in manufacturing. If you don't follow Deming's rules these days, you no longer exist, and you can't begin to compete. Dr. Deming said "Aim defines the system." The first thing you have to be very clear about is what you hope to accomplish. If our aim is very rapid response to people suffering or facing death with very "high touch" then the current system is about perfect. If your aim is health, then the current system is entirely off track.
The question is what are we trying to accomplish with this system? Most people at some level believe that it really is health, but if we really believe that we'd do what the Swedes do. They invest two-thirds of what we invest and achieve a far better health outcome at the level of longevity for example. How do they do it? It comes from careful education in their elementary schools to begin with and then all the way through about behaviors--a much better use of tobacco, much wiser use of alcohol, safer health habits around things like sexually transmitted diseases. There are so many things that you can do that have such a big impact at that level. Well let’s just say in the United States we don't invest over there, we invest in that acute response to somebody suffering a critical need. In other words, what we do... we wait until you get really, really sick and then we pull out all of the stops instead of acting early so that you never get sick in the first place.
Interviewer
Are we already spending enough money in our system to cover everybody?
Brent James
This year we will spend $6800 per American on health care delivery. That's roughly twice of what the rest of the world spends. It's 2.2 trillion dollars. It's 2.2 million, million dollars. It's roughly four times what we spend as a country on defense, even with the Iraqi war effort. It's a massive expenditure. It's not just that it's enough, it's probably too much. We have good reason to believe that because of waste within the system that we could cut that by almost half and get a better health outcome result.
Interviewer
And yet we don't.
Brent James
We don't. Boy how to explain that in simple terms? No we don't address the waste in the system. It's probably due to two main things; the first is tradition. There is a way that healthcare delivery evolved and you're kind of stuck in the past, if you will. Change is hard. The second is more profound. The best term I have for it, I guess I'd call it the Medical Industrial Complex. It's called the Medical Industrial Complex. It's the idea that one man's waste is another man's profit.
It's called the Medical Industrial Complex. It's the idea that one person's waste is another person's profit and it's endemic in the system. What you find are these big companies who come with some new idea that they argue will improve someone's health usually in an emergency setting. The trouble is that very often the amount of improvement is tiny and the amount of cost is huge. Now they definitely don't want to bring that to a standard market place. If you were paying for that out of pocket, you'd never buy it, so they want it to be part of the public system so that it's free to the people who would use it. You need to know that physicians participate in it very, very heavily from time to time, so you find physicians who have high amounts of what are called passive income. They get paid more when they refer you to a particular service. Sometimes it's a service they supply themselves, so you see physicians who actually make more doing x-rays, MRIs and other imaging than they make caring for patients, and they can literally become multimillionaires doing this thing.
Well, that means that other times in the past when we've tried to improve access massively by controlling that waste there's a massive incentive for people who are engaged in the Medical Industrial Complex to counter attack. They're perfectly willing to invest tons of money in a political campaign really; a media campaign to destroy that kind of an initiative. They sometimes make common cause with a group of Americans who you have to respect intellectually. These folks really believe in equality. They believe that it's immoral that one person would have access to more services than some other person regardless of the level of service involved--a small group. It's very idealistic. It's not pragmatic at all, but when you combine that logical argument with big money for people who are becoming very, very wealthy feeding on the system, right, that's the Medical Industrial Complex. And in the past, initial efforts to try to solve this have run straight up against it and lost fairly consistently. Now the trick is, is that the problem is becoming so massive that something has to change. Sixteen percent of the gross domestic product, simple projections in current growth rates in healthcare based upon the change in population, the fact that as a people we're getting older and we use more services as we get older--it suggests that this is going to increase to no more than 20% of the gross domestic product across the next couple of decades, and it appears to be unsustainable.
Interviewer
Is this a crisis we're in?
Brent James
We're currently spending about 2.2 trillion dollars a year on healthcare, that's about $6800 per person in the United States every year. It's 16% of the gross domestic product, and it's increasing rapidly. There are changes in our basic underlying population that are going to drive it up hard, and it's unsustainable. It's clear that we cannot afford that kind of healthcare in the future because of what it pulls out of other key sectors of our economy--out of education, out of basic infrastructure, out of our ability to compete internationally--our ability to maintain a dynamic, growing economy that feeds Americans, houses Americans, educates Americans as well as maintaining their healthcare.
The main driver behind it is the Medicare program--the federal program for people over 65 years of age. Yeah, we've been saving money against that future need. That money runs out in about another five or six years, and that will call the question--that will force us to respond. We simply can't sustain the rate of growth that we face today. You know another way of saying it... when I talk about spending $6800 per person per year, it's about twice of what the rest of the world spends. More important, consider a typical family of four. It means that a health insurance premium today is almost the same as the mortgage payment on the median American home, a $211,000 home. Well if you had to choose, would you rather have a home to live in or would you really have health insurance, because that's choice that we're coming to. It's simply too expensive.
Interviewer
Are there answers out there that are viable right now?
Brent James
There are some very viable answers for controlling this thing. Here's a few of them that are in the mix that are in the play of how you make healthcare accessible to all Americans. The first is the work of Dr. Jack Weinberg. He's at Dartmouth University. He publishes something called the Dartmouth Atlas. He has carefully compared Medicare recipients living in Florida to similarly situated people living in Minnesota. It turns out the people living in Florida consume two and half times more federal dollars per year than the people in Minnesota while getting a worse health care result, two and a half times more of this expensive system. It's directly associated with the proliferation of medical specialists and hospital beds. Lots more specialist visits, lots more testing, lots more hospitalizations. Even you just assume the hospitals are kind of dangerous and they have a risk associated with them, and you're putting people in hospitals where there is not benefit, but lots of money coming back to the Medical Industrial Complex right, then you can explain the higher mortality rates just from the risk associated with the hospital. Oh just in passing, Dr. Weinberg has shown that Utah is the most efficient state in the United States of America. His methodology removes the effect of our younger population and the very potent effect of a Mormon population. It turns out the Mormon lifestyle is associated with much lower healthcare consumption. He accounts for that, he removes it. We're still the most efficient. What Dr. Weinberg says is that if the rest of the United States were to deliver care the same way we do in Utah, that the cost of Medicare would drop by 32% immediately while mortality rates would improve by about 2% and we would not have a healthcare financing crisis. We wouldn't be talking about access. So what I'm saying is the solutions are there. It's not just that we know how to do them; it's that people already are doing them. It's the political will and overcoming those entrenched in political factions that have so much to gain by perpetuating the current system.
Interviewer
And in Utah it seems like we should be especially poised to do something about our access issue. How can we still have 300,000 or so uninsured people?
Brent James
Currently the uninsured in Utah make up about 16% of our total population. We're just a little bit above average for the United States as a whole. Now you have to understand that the uninsured really fall into three big camps; the first are among the uninsured about one third of them could afford health insurance if they chose to get it--we call them free riders. They just don't see enough benefit from the health insurance in their personal lives to justify the expense. They know that if they have a major medical problem we'll give them the care anyway through the charitable care system and that will be a transfer cost right onto the rest of us who do pay insurance--so free riders. It's not just free rider individuals; it's also free rider companies. So some big companies choose not to give their employees health insurance. It's just a way of reducing the costs of hiring those employees and then they transfer that off on the rest of us, and that's about a third of the uninsured. Another third of the uninsured are in transition. They have employment-based health insurance while they change jobs, and so typically for--I think it averages about 4 months, a relatively short time period--they'll be uncovered. But you get all of these people who are transitioning, and that's about a third.
Only about a third of the uninsured are the truly uninsurable, usually because they go outside the health system, had a major problem and now because of something called underwriting--how we handle insurance--they can't get anyone to give them an insurance policy coming back in. Yeah, in Utah we should be able to address this problem. You see the problem is it’s all relative isn't it? Despite the fact that we're a third lower than the rest of the country, it's still pretty expensive, and the question is how much do we as a people want to spend on healthcare for the group, if you will?
So to understand that, a question I like to ask my classes when I'm teaching quality theory to physicians, nurses, senior healthcare executives, I like to ask them if healthcare is a human right? You know the trouble is, is that language is so loaded when I use the word "right." Nearly always someone in the class will say, yeah, I think it is. So I push back on them a bit and I say, "So that means that every person ought to have access to the most expensive treatments and the finest medical centers." Everybody backs off and they say, I don't mean everything to everybody, I mean to some level. What they're hinting at is a core piece of political theory. It turns out there are two kinds of "rights" in the world. The original use of the word "rights" was for something called proscript rights. They are detailed in... Well the Bill of Rights, the thirteen first amendments to the United States Constitution. The five big ones that are covered for a typical American are freedom of religion, freedom of speech, freedom of association, freedom of the press and the right to bear arms. The other eight are technical, legal rights. Proscriptive rights... the really neat thing about them is it doesn't really cost anything to enforce them. There are things the government can't do to you that are innately part of you as being a human being.
Those stand in contrast to what are called prescriptive rights. Prescriptive rights are rights where we agree as a people that the government has to give you something, and that does involve some very big expense, the three big ones? #1: a right to food and shelter. Food and shelter is much more central to life, liberty and the pursuit of happiness than is healthcare, so everybody has the right to live in the finest mansions and eat at the finest restaurants? Well no. Technically you have a right to two years of subsistence living. We put at limit on it, a cap. The second big right in society - education. It's called a merit good because we all benefit as the education level of the country goes up. Well everybody has to right to pursue their life dream of personal development at the finest Ivy League schools as long as they want to? Well no. You actually have a right to a high school education. Two states in the nation, California and New York try to extend that into University education and really struggle with it because of the expense, in other words we put a cap on it.
How about healthcare? You see part of the debate that we're having is should everybody have a right to unlimited healthcare? And for other prescriptive rights we never approach it that way. A funny thing happened to me. I was teaching our courses in Sweden so I had a room full of Swedish physicians. I went there because they have the reputation of being the finest socialized medicine system in the world. And on all the data, all the graphs, they look great. So I posed the same question to a room full of Swedes. "Is healthcare a right?" They laughed me out of the room. They told me that I'd made a fundamental mistake. They said you shouldn't use the language of rights to describe this problem. I said, "Well what would you call it?" They said, well we think of it as a shared social benefit. That's a very important distinction. They're not saying it's a right, it's something that we as a people agree that we're going to share, and they say the reason that's important is you can put levels on it. It's the idea of a prescriptive right where I'm going to say everybody has a right to this level.
I just finished serving for three years on something called The Citizen's Healthcare Working Group. It was established as a law from congress. We were tasked to measure the values of the American people relative to health care. I just sent in a report to the President. I'm waiting for his response back to our report. We asked the question carefully from several different directions and got a very, very strong response. Americans believe that healthcare should be a shared social benefit across all of society, two-some level. They don't mean all care for everybody. They believe that if we have to limit the amount of service delivered to each person in order to cover everybody in the country, that's what we ought to do, you see. Now what I'm talking about is called an explicit two-tiered system. That means that well, we agree as a people that everybody gets this level of care regardless of your ability to pay, but if you want to go beyond that into the things that are very expensive for questionable value, you're on your own. Pay for that out of your own money out in a free market. You know, buy your own insurance for that. That's the idea behind it, and it's a very powerful idea. Sometimes you hear it described as a core benefit package, is the name for it. People have been experimenting with Medicaid for years now to achieve access so, for example, when Mike Leavitt was Governor of Utah, he sought a special federal exemption so that in Utah we could drop the level of service to cover many more Utahans with basic services healthcare; the kind that can really make a difference, that can really benefit your total health, that's the idea behind this thing, and the question then becomes, can we somehow put together that shared social benefit on a broad scale?
Interviewer
What is a shared social benefit? Define it.
Brent James
A shared social benefit means that we as a people politically decide that this is of enough value to everyone in society that we both share the costs of some level of benefit, and at the same time, we get the benefit back personally, so it's public education. It's the idea of a welfare system for basic shelter and food. It's the idea of some level of healthcare delivery--where everyone has access to that level, regardless of your ability to pay. It's the idea, the basic idea of why we have taxes. It's the idea of a shared defense--that we support the military together as a group. It's the idea of the postal system, you see. That's a shared social benefit.
Interviewer
So is there anything that you think that we really need to look or know in terms of as a society around the notion of spending and access—something that we need to urgently be aware of?
Brent James
There is something that everybody ought to understand. We just finished a fairly careful study that conservatively estimated that at current ways that health care is delivered, over half of all money spent was waste, was non-value adding, did not promote the patient's health. It was a very careful study. If we could somehow address this question of waste and healthcare, we wouldn't be having a conversation about access. Healthcare costs would be a fraction of what they are today while people got better medical outcomes--that's the real challenge. We're about to enter into a major national debate about healthcare reform. It's going to be in terms of government policy--what should we as a people do? The point is that real reform always happens inside-out, not outside-in. You have to change the way those physicians and nurses and hospitals and clinics behave, you see. Can outside-in policy have some influence on that? Yes, but it only works to the degree that it actually changes those inside-out behaviors. That change is starting to happen. It's happening from the heart of the medical profession and the nursing profession. We've started to very carefully study what we are, how we see ourselves, how we do our business, how we help people, and as we've examined those things we've found some pretty stark failings and real opportunities to do it a whole lot better
The big change that's taking place has to do with the mindset particularly of the physicians. We use to have this old model of heroic individualism; the physician as a stand-alone expert, a law into themselves, you know, next to God in their knowledge about the human condition and their ability to help. Well back 40 years ago that may have been true, but markets will die when the actor died. Today it's no longer one physician delivering all of that care. It's always a team, and we're seeing a transition out of the era of the heroic individual into a team-based approach. Medicine is a team-based sport, I guess. We found that as you start to coordinate a natural system of care around that team, much better patient results, in terms of whether you live or die, much better "high touch" in terms of relationships with those health professionals, and substantially lower costs-- that's where the future lies. That's where we're going to solve this problem in the next decade or two decades.
Interviewer
What can I as a nonprofessional do?
Brent James
As a nonprofessional there are some very important things that you might think of doing. The first is, is the demand change. Demand change to point out that 2.2 trillion dollars is more than enough and that this healthcare phenomenon is sucking too much out other parts of our economy. Demand that change! Demand it not just politically, but as you look at the healthcare system, find effective teams. It's easy to recognize the signs. It's clear by how the nurses and physicians interact together, that they're coordinated. It's clear that they're putting the care in your hands, you as the real line of defense, the first decision maker. Their job is to support you, not to mandate what you'll do. Be highly skeptical of the solve-it-all treatments. There are thousands of them out there. They make these egregious promises and nearly none of them come through on them. So be a little bit skeptical. In other words, take the time to educate yourself right, and don't take any wooden nickels along the way.
A step beyond that, look to your own health. Remember how we mentioned that 40% of your total health comes from your behaviors? You’re the most important person in your health, far more important than any doctor or any nurse or any healthcare delivery system. Well take responsibility for your own health. The big mistake that people make is they screw it up right. They get in health trouble, and then they come to a physician and expect us to make it all better. Physicians love that role. We're those heroic individuals who want to be able to, you know, turn back time to define a new future, but it's a basic lie. It's never as good as it was originally. Well take the leadership. Take control of your life. Step out on the things that make a real difference so that you don't need me, so you don't need the doctors, you don't need the hospitals, you don't need the clinics nearly as much, and you can make a real difference in your total health, and at the same time make healthcare delivery much cheaper.
Interviewer
Internationally, the debate is often around Single-payer vs. market driven systems. What are your views on that?
Brent James
There are many people in the United States that are really promoting single-payer systems. A better name for it would be government controlled healthcare. There are all different ways of implementing government controlled healthcare. It appears to work fairly well, in a particular way for other countries like Canada or like Sweden or like Great Britain. Here's what you have to look for underneath though. Here's why they work; in those systems where it's controlled by the government, the first thing that you do is you separate primary care from specialty care, alright, and you really emphasize primary care--you fund it very liberally. The reason why primary care on average is quite cost effective, you get relatively big bang for your buck. There are a lot of good health results for a relatively small investment, and it's very "high touch." So through that "high touch" you can well, feed the rule of rescue if you will. So that's the first thing you do. Over here is primary care heavily funded so people can get fast, easy access to talk to a physician.
You realize that most of the actual expenditures are coming from the secondary care system where it's much higher costs and much more questionable health results when we're in crisis mode, you see. So in those countries they explicitly limit the number of specialists who can practice... completely different from the United States. You know Canada actually has quotas on how many specialists can practice? They usually require that they're an employee of the healthcare system which means technically an employee of the government. They explicitly limit the number of hospital beds, again high-tech side. They explicitly limit the number of MRI scanners and cat scanners and high tech therapies that can be performed within their country, the number of kidney transplants, and the number of liver transplants. They force people to queue up and wait to get into those things, queuing--a waiting line... that's just a way of limiting access or rationing services. Because of that they tend to get a whole lot more leverage from their funding of healthcare around the things that seem to count most to people; easy access, high touch, and really cost-effective public health types of services than we get here in the United States.
You also do need to control the primary care network. They can spend out of control too. So for example, one of the best examples up in British Columbia and Canada they have a provincial estate budget for that each year. The primary care physicians are actually independent practitioners--private businessmen and they treat you as a patient and then they send a bill to the government for their services and the government pays the bill. It sounds very attractive. The trick is, is that they do have that budget for all of primary care in the province. If at the end of the year, the primary care network--this group of independent practitioners, have overspent their shared budget, well they account your portion of the coverage based upon your billings and you get a letter back from the government saying please send a check for $10,000. That's your share of the overspending, and as a physician, I'm required to send it in or go to jail. As a result of that, when I'm sitting to talk to you as you being a patient and me being your physician, it will change what I offer to you. I will not even give you an option for things that I regard as being low-cost effectiveness, as having a big expense with a low potential benefit. In some sense I'll lie to you by withholding that information, you see? And that's how it works. Other provinces are a little bit craftier politically.
Interviewer
So basically there is a form of rationing going on in the system?
Brent James
In any system there is what we call health care rationing--it's the idea that there's a limited amount that you can supply as a shared social benefit. In the Canadian system, the Swedish system, the British system--everybody but the United States--that rationing is done basically in a smoke-filled political back room. As they choose how big a budget is for primary care, and how much technology they're going to allow at a secondary care level. It's carefully hidden from public view you see.
In the United States we attempt to ration through market mechanisms, but it still happens, and that's how we limit how much people can purchase in the United States. It's not a question of whether you're going to ration, it's only a question of how you're going to ration. Rationing is really kind of a bad word for this. We don't talk about rationing education. We don't talk about rationing food and shelter, right? We talk about them as shared social benefits and we talk about how much we can afford to supply to each citizen. It's a much wiser, more accurate way of talking about it you see.
Now, one last little piece you might find useful--Dr. John Kitzhaber spent several years as the Governor of Oregon. He was looking at access issues particularly, and he was particularly troubled by one thing. Within the United States we ration people, not services. Here's his description of it; he said, imagine the following--you and your spouse are both working, you have a relatively large family, well you go into work one day and out of the blue they pink slip you, they fire you, do a reduction in force. You're home that night and it's a somber affair as you sit around the dinner table. Your income has just been cut by roughly half and it's going to be awhile before you can find work to replace that good job you had before. Well yeah, you're considering this in a state of mild depression and you look over the fine spread that you have on the dinner table as your children eat. You look across that and you realize in the future we're not going to be able to afford that. So you look down through your children and you pick your six year old, your little girl and you say, “Susie, I'm sorry you can't eat anymore so that the rest of us can continue to have anything we'd like at all--any type of food, any amount of food. Sorry you can eat.” Well that's rationing people you see.
Well when we posed this question to the American people as the Citizens Healthcare Working Group, we got a very distinct answer back. Over 90% of Americans said that we shouldn't ration people, we should ration services. It's that idea of a shared social benefit. Yeah, today the American Healthcare System rations people. If you have insurance you get everything--the sky's the limit. You know pull out all the stops, never hold back. If it might work let's do it, right? On the other hand if you don't have access to insurance you're on your own, you get nothing. That's what the charitable care system gives you is scraps falling off of the table you see. Well you decide. Should we be telling our six year old, you can't eat? That's the idea of a shared social benefit. Or should we be saying that if we need to cut back we'll all tighten our belts--we'll ration services, not ration individual people.
