Treating the Least Well Off

To the Editor: Who can argue with the obligation to treat "the least well off" that Rosenheck and his colleagues (1) articulated in their consensus statement in the October issue? Their desire to use the resources of the Department of Veterans Affairs for the least well off is described as the essence of fair play, justice, even the American way. However, it is troublesome to me because I am uncertain whose care they do not want to fund. It is troublesome because I don't see this argument elsewhere in medicine—that we shouldn't treat hypertension until a stroke has occurred. But it is most troublesome because it ignores the social context in which the VA and, by extension, other publicly funded health service programs exist.

As a nation, we do not commit our resources by need alone. Instead, we tend to rely on the market so that those with private resources can purchase what they want regardless of their relative need. We use public monies to provide care for those who can't buy needed services on their own. The argument advanced by Rosenheck and associates is that these public monies should be targeted to people they identify as "least well off," those persons with the most severe mental health problems.

But why do we need to redistribute public funds alone? If the argument of need is compelling, why does the statement not ask that more private monies be consigned to the public sector to cover all in need? Why remove some impoverished individuals from services to benefit another group of poor individuals? Obviously, the politics of redistributing monies to the poor is challenging and contentious. Isn't this statement at risk of avoiding these politics by pitting the poor against the poor? Where is the courage or leadership in that?