Rationalizing Rationing – Health Care Reform Exhausted
Before you sigh in exasperation, roll your eyes with irritation, and perhaps even let out an almost audible groan in sheer agony, I promise that in the remainder of what I am about to say, the words “health care” and “reform” will never appear adjacently. This has become the new MJ.
Having just graduated with a Masters in Health Management and Policy, I may seem an unlikely candidate to wish that my field received less media coverage, but my head might just combust if our president continues to appease the greater public with pledges of “no socialized medicine”, “no rationed care”, and “if you like your plan you get to keep it”.
By now we are well acquainted with the 1 in $6 that is sure to become the 1 in $3 in 30 years. We know it’s urgent, it’s dire, and the fiscal future of our country depends on it. We are also aware of the fact that in our current system 90% of health care dollars are allocated to 10% of our population, and nearly 28% of the Medicare budget is spent on patients’ last year of life. This is hardly an equitable appropriation or efficient utilization of scarce resources.
Wait, did I just say efficient? If it seems that I am making a judgment about the value of one’s last year of life, it’s because I am. But the monetization of American lives is not new. The EPA allows drinking water to contain 7 million Asbestos fibers per liter because they could not justify the amount of capital would be required to achieve a lower or zero fiber count. We tolerate a level of risk, chance of injury or death in all that we consume (e.g. bacteria on produce) and do (e.g. working in a factory), because to eliminate them would be exhaustive. We have, for everything else, allowed our government and various private industries to valuate human life and set standards accordingly. Why not for health care? Why not establish a standard guideline that excludes non-cost-effective treatments and procedures? Do I stand alone when I say that I’d rather receive a course of treatment endorsed by an elite team of medical experts rather than rely upon the knowledge of one physician I randomly encounter?
The 11th floor of St. Joseph’s (a community hospital in Chicago) is filled with elderly cancer patients, many of whom have lost most of their cognitive functions. They are confused and in pain. It may sound callused to say, but they are also consuming an exorbitant amount of resources. I am almost positive that the care they receive would not meet the QALY (Quality Adjusted Life Years) per $X standard many are proposing. I am okay with that. And I suspect that they would be too.
I realize that my life (as well as the lives of my loved ones) adds a certain amount of value to society and I feel comfortable knowing that this society may not choose to exhaust its resources to preserve it. So I extend this question to everyone, can you make peace with health care rationing?
4 comments:
I do agree that health rationing should occur. Economics talks about the law of diminishing returns, and exhausting so many resources to prolong a life is irrational. But as long as consumers are given the option to "keep going," they are going to let their emotions do the talking and insist the doctors continue to fight, no matter how futile the battle. And who could blame them? I would never choose to pull the plug on a loved one as long as there was a sliver of hope that they could rehabilitate, not only because I love them so much, but because I don't want to be the callous bitch that signs off on something like that. My conscience would kill me. But if doctors removed my say in the matter and health care was decided by objective cost/benefit analysis, we would have a more efficient (less emotionally-driven) system.
There is no easy solution to this problem. Canadians bitterly debate the benefits of allowing the development of a "two-tier," "American" system, while in the US, "rationing" is a dirty word. The solution will not be one simple health care plan that comes in a neat little package with a bow on top. Ideas on how to pay for and distribute health care will continue to change as technology and population demographics continue to evolve. Who is going to pay for the care - government vs insurance companies vs private citizens - is only half the question. The other aspect we cannot forget is how to increase the efficiency of health care delivery, using information technology, better coordination between specialists and primary care for complex patients, and increasing the emphasis on public health measures.
I've tried to be slow in my response, hoping that the more I thought about it, the more my gut reaction would evolve (especially when I saw that it is similar to Rush Limbaugh's gut reaction), but it hasn't.
I heard a relevant story on NPR's Radiolab podcast, "After Life.” In the distant past, a person was declared dead when she stopped breathing (as seen in King Lear). A little while later, death was when a person's heart stopped beating. In the sixties, when for the first time we had the ability to restart a heart, all kinds of patients were brought back to "life" but left brain dead and taking up room in hospitals—that is until a doctor (can't remember the name) determined that it was inefficient and convinced the medical community to accept brain death as the new standard for . . . death. Death never has been an exact science, and so I’m uncomfortable with yet another change based on the bottom line.
This entire debate over government vs. insurance companies has flaws. A major flaw is that although insurances like auto insurance, house insurance and life insurance are almost exactly the same in theory (large amounts of people paying small amounts of money into a central pot so small amounts of people can use large amounts of money), they lack the same emotional power of health insurance. Another flaw is that we see health care as a different expense than things like food, water, shelter and utilities. This means statistics are thrown around constantly which I find distracting to the true debate.
First: 1 in $6 to 1 in $3 is spent on health care. Why is that such a terrible thing? Most of the time people spend in upwards of 25-30% (1 in $4) of their income on mortgage payments/rent (while some haven’t been able to pay, most of those were in excess of 40-50%). Why is that percentage acceptable and yet a lower percentage on something much more important is urgent, dire and disastrous? Isn’t health care something we work for? Don’t you have a job to provide a place to stay, food to eat, and medicine for your family? This is why we save money. This is why we shouldn’t spend everything we have on entertainment and transportation.
Second: 28% of the Medicare budget is spent on the patients' last year of life. This statistic has some meaning but not the great one others place upon it. Actually, it's a little obvious. I don’t understand the great consternation over this (I’ll write about rationing next). My uncle, who recently died of cancer, spend much more in his last few years of life fighting cancer than he did in the 58 previous ones.
Third: 90% of health care dollars are allocated to 10% of our population. This is a meaningless statistic. The 10% most likely consists of the sickest and those who have accidents, Joe may remember Jeremy McGill. He spent around $100,000 on medical care, half of which was covered by insurance. So, of course they are going to spend a very high amount of money over the most healthy 10% and those who don't have accidents. That's like saying the fattest 10% of people eat a majority of food. It's true, but has very little meaning because it’s not connected to rationing. Rationing happens everyday in many different areas. People ration the size of their house, amount of food, clothes, entertainment they buy, even the amount of children they have. We don't call it rationing, we call it being frugal. (I recognize a difference in our view of these things and health care, but in theory they are all the same.) The statistics you should care about is price and quality. How have services such as CAT scans, MRIs, etc gone down/up in price over the last few years? What drives this gain/loss? I think that these are the significant statistics we should be focusing on. The rub comes in with then who decides the rationing. I want people to decide their own rationing. If you do not have enough money for care, ask for donations from others to help. In Tennessee we often help others who have cancer through yard sales, benefit cookouts, and sometimes straight donations. I do not want the government to decide rationing. Often government officials and rules do not follow my morals. I want to be in control of my money.
So, to sum this up because it's becoming very long, be careful what statistics you use when you talk about health care. They may look interesting but may not have very much significance. But to specifically answer the question, I don’t think the question is between rationing and not rationing but between free individuals and autonomous companies making the rationing decision and the government making that decision. I say let individuals do it. That’s freedom.
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