Today’s news is full of commentary about work requirements for Medicaid. Is work a prerequisite for health care or is health a prerequisite for work?

Not to complicate things, but can we even agree on what health care is? I don’t think we can, and it largely falls back on what we want to share in paying for.

A patient with an ugly skin lesion can have it removed if it might be cancer or if it bleeds or causes pain. If it is just ugly, it’s considered cosmetic, and insurance won’t pay for it.

A man wants a vasectomy, while another one regrets having one and wants it reversed. Is one procedure more medically necessary than the other and more deserving of societal cost sharing?

Even the most esoteric medical procedures, like freezing embryos or cloning children, could be called health care, but may not have society’s support when it comes to being necessary or desirable.

And, even as we speak, what about abortions? Are they health care or not?

In many ways, I think life was simpler practicing medicine in socialized Sweden. The government paid and the government made the rules. Here, the government makes some rules, the insurance industry makes others; the government pays for some people’s care, and the insurance industry pays for others. And the insurance companies all have different rules.

Since health care costs twice as much in this country as anywhere else in the world, it seems painfully obvious that we need to talk about what the purpose of health care is and, from a moral perspective, what we have a right to expect our fellow countrymen/women (if not citizens) to pay for.

It is remarkable that such an enormous slice of our budget and our life so much lacks definition and almost seems to be taboo to openly try to debate.

If we look at other aspects of cost sharing in our society, can we draw any useful parallels?

If a high school senior wants to repeat his senior year because he had so much fun, should he be able to do it for free? (Just a hypothetical example; I don’t know if anyone would really want to.)

If a child calls the fire department every time she smells smoke from the family barbecue, should the town charge the family or stop sending a fire truck?

If an amateur sailor capsizes every weekend and always calls marine patrol, should they keep responding?

In social policy terms, the word entitlement is used to define programs like Medicare and Medicaid. I think that is an unfortunate and very loaded word. Contrast that with another word that I personally keep coming back to: stewardship.

It is time for a serious conversation about balancing stewardship and entitlement in health care. At least as long as it is not all self-pay: Taxes or insurance premiums both imply we want someone else to pay for some or much of what we think of as our personal health care.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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