HJNO Jul/Aug 2025

HEALTHCARE JOURNAL OF NEW ORLEANS I  JUL / AUG 2025 53 Medicare and Medicaid. Historically from the provider/hospital perspective, part of the problem of uncompensated or under- insured care was addressed through differ- entiation of private versus public hospitals. Public hospitals received a combination of state and federal funding to provide care for those in need, but unable to afford private health insurance. These public hospitals gen- erally made excellent training grounds for medical students and residents who were at- tempting to earn the credentials that would allow them to enter private practice and pur- sue their chosen career paths in medicine. I was a beneficiary of that type of train- ing, and it shaped the way I have prac- ticed medicine ever since, which is typically in accordance with a consensus of sci- entifically derived evidence-based principles. First, as medical trainees, all of our decisions were typically examined and questioned by senior faculty members who themselves were already experienced clinicians. These faculty members aspired to a professional path in academic medicine and as such were typically very up to date with the latest articles pub- lished in the most esteemed medical journals and were generally considered by their peers to be the best and brightest of all physicians. Second, in this public hospital setting our medical decisions were not influenced by fac- tors such as what would generate the great- est amount of revenue for our institution. If anything, we were encouraged to deliver the best possible care at the lowest cost possible, since our institution had limited financial re- sources and depended on taxpayer-supported financing, as opposed to some of the more profit-driven incentives of private practice. These public hospitals made for great train- ing, but unfortunately also led to obvious healthcare disparities and inequities, as many of the public hospitals were limited by an ag- ing and even antiquated physical infrastruc- ture, often lacking the most up-to-date tech- nology. In recent decades these traditional public versus private models have evolved to public-private partnerships, giving medi- abuse, malnutrition, and other issues that emer- gency rooms are ill equipped to manage. There are also numerous visits for mild ailments that could have easily been managed in a primary care setting and that cause avoidable conges- tion in emergency department waiting rooms, since by law the ER cannot turn a patient away. These patients will receive bills — usually ex- pensive ones — for services rendered but often may lack the ability to pay. The result is that the hospital provides care for which they receive no remuneration. These hospitals then go to commercial payers demanding higher reim- bursement rates to offset the costs of uncom- pensated care, which ultimately get passed onto all of us who do have health insurance, albeit in the most expensive form possible. I have been watching the HBO Max series “The Pitt” recently and think it is an outstanding show that realistically — although a bit dramati- cally — captures some of the heroics of these dedicated ER clinicians in action while also struggling mightily with some of the prevailing cultural issues of our time, like gun violence and opiate use disorder. These “deaths of despair” have contributed to a decrease in life expectan- cy in our country for the first time in decades. And when one looks at the epidemic of physician burnout that is gripping our country, ER physicians often top the list of physicians most affected. The show does a very good job of illustrating why these physicians find themselves so afflicted. The emergency room — along with primary care physicians (who are also usually at the top of the list of physicians suffering from burnout) — are on the front lines of care delivery and the ones most impacted by the downstream reper- cussions of our failure as a country to confront the upstream realities of social determinants of health and chronic conditions, and dare I say the failure to consider healthcare a human right. Public versus Private In the last two articles, we reviewed the his- tory of how private insurance started in this country, but how its failures ultimately led to the first public insurance models, through We started this series of articles attempting to answer the question “What’s wrong with healthcare?” by exploring the history of health insurance and how private market health in- surance began and evolved in this country. Next, using the influential article titled “The Struggle for the Soul of Health Insurance,” writ- ten by Deborah Stone in 1993, we sought to ex- amine the very essence of health insurance. The U.S. remains one of the only economically de- veloped countries in the world that stops short of considering healthcare as a human right. Advocates of the position that healthcare should be a human right for all citizens of our country cite the clause “promote the general Welfare” in the preamble to the U.S. Constitution as support for their position. The Due Process clause of the 14th amend- ment to the U.S. Constitution, “… nor shall any State deprive any person of life, liberty, or property, without due process of law,” has also been used legally to defend the position that healthcare is a human right. Though not part of U.S. law, the Univer- sal Declaration of Human Rights — adopted by the United Nations in 1948 and generally supported by the U.S. — states: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including … medical care….” Healthcare as a Right? As mentioned in the last article, our nation has resisted the notion that every member of society should have health insurance, espe- cially if that means mandating that they pur- chase insurance, although we seem to have no problem insisting that they purchase auto- mobile insurance. As a result, we have ended up in this unclear area where healthcare is not guaranteed as a right when it comes to pri- mary care and preventive care, but where we are unwilling to turn our back on a person in need if they present to the emergency room in a real or perceived state of acute crisis. Consequently, there is a deluge of patients presenting to emergency rooms with social problems such as homelessness, substance “The only mistake that physicians seem to fear is doing too little.” — Atul Gawande, Being Mortal