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If You Have a Right to Health Care, How Much Care?

Hat tip to Kevin M.D. for calling my attention to “The  Covert Rationing Blog,” where Dr. Rich offers a concise summary of the dilemma we  face as we move toward a consensus that health care is not a privilege, but something that every human being should have. (One can call that a “right” or a “moral obligation that a civilized society has to provide health care to everyone.”)

The point Dr. Rich is making is that once you decide everyone deserves health care, the question is “how much care.” As he puts it:

“Exactly how much health care are you entitled to  if you have a right to health care?  Do you have a right to certain  specified health care services, to a certain dollar amount of health care per  year or per lifetime, to  whatever health care it takes to achieve perfect health, or to some other limit or non-limit?

“The question of limits (whether we should have  them or not, and what should  they be) has been a central theme of this blog and of DrRich’s book. To reiterate the fundamental problem: 1) In America we believe that it is wrong to limit health care in any way, that  everyone is entitled to the very best health care, that any bit of health care that offers even a small potential of benefit should be provided, and that death itself is merely a manifestation of insufficient research (or actionable incompetence, or systematic discrimination against the  unwealthy, or corporate greed).  2) But against that closely held belief, we must balance the unremitting law of  economics which tells us that there is simply not enough money in the known  universe to buy all the health care that might potentially offer some small  amount of benefit to every person. Health care spending has to be limited,  or it will become a fiscal black hole.”

Dr. Rich is correct on all counts. Our American love affair with medicine — and in particular, medical technology — is all  tied up with our fear of death, and a feeling  in some quarters, that “American optimism” demands that to strive for immortality. We put such emphasis on the individual, and the individual ego; how can we accept that, someday, it will be extinguished? (I’ll always remember the doctor who told me, in an interview, “Of course, one day, most people will die.” I wonder who he was  excluding from “most people”? )

In my recent post on medical technology driving health care costs, I suggested  that we need to begin setting limits on that technology. This is especially true if we are aiming for universal coverage.

Here we need to recognize that covering everyone will cost more—much more. Some well-meaning reformers have suggested that  once everyone has access to care, we will save money because those who are now uninsured or underinsured will receive preventive care. The theory is that, today, the uninsured wind up in the hospital—where they receive very expensive care—because they didn’t get needed care in a timely fashion. I should acknowledge that in the past, I have made that very argument.

But sometime over the past year or so, I have come to realize the ugly truth:  the uninsured die sooner than the rest of us. By leaving a significant portion of the population poor, and uninsured, we save money.

As the new Synthesis Project by the Robert Wood Johnson Foundation, “High and Rising Health Care Costs: Demystifying Health  Care Spending,” reveals, studies consistently show that when a large portion of the previously uninsured population  becomes insured, total health care spending rises by 10  to 13 percent.

Indeed, this report by the Center for Healthcare Systems Change (HSC) shows that, over the past decade, the decline in the percentage of Americans  who have insurance has slowed the rate of health spending growth. If everyone had been insured, our national health care bill would be even higher.

As Dr. Rich puts it, “steadily increasing the  number of uninsured Americans has become perhaps our most effective mechanism of covert rationing. This simple expediency alone goes a long way toward enabling us to avoid having to consider or discuss limits.”

This is because while preventive care will keep  some previously uninsured patients out of the hospital, they also will live long enough to fall victim to very expensive diseases like Alzheimer’s, and certain cancers. Moreover, the previously  uninsured, like the rest of us, will be overtreated. Unless universal coverage includes some very intelligent rationing, that many more people will receive  unnecessary tests and scans, leading to unnecessary procedures.

This, of course, is not a reason to leave a large segment of the population uninsured.

But it is a reason to take Dr. Rich’s argument seriously. Now that we seem to be reaching agreement that we no longer want to ration care according to ability to pay, we will have to begin discussing how to ration care some other way.

It seems reasonable to begin by refusing to pay for treatments that are only marginally effective, giving the average patient only a few extra months  of poor quality life. But if “on average” patients live only a few months longer, that means that a few patients will live nine months longer. And we cannot know we they will be. Yet our resources are finite.

It strikes me that before we pour vast sums into customized medical care based on genome research, we might ask whether we, as a society, will be able to afford such care. Or will this be medicine only for the wealthiest few?

Perhaps rather than focusing on technological progress, we should focus on harnessing the technology that we have now so that we can understand it better, and use  it more efficiently, for the benefit of the  population as a whole. After all, what is the point of universal coverage if we  cannot afford to provide universal care?

All of this winds back to our vain effort to somehow “beat  death.” We keep pushing the envelope, in hopes of living longer. But living longer only means dying of something else. And, too often, it means that the body outlives the mind. Wouldn’t it be better  to aim for a higher quality of life, for all of us, for eight decades, or perhaps nine — rather than striving to see how many of us can totter over the finish line at 115.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of  “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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MD as HELLrbarJoePeterMikeC Recent comment authors
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MD as HELL
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MD as HELL

OK, let’s start with these questions:
1: Who is NOT going to get a PEG tube?
2: Who is NOT going on dialysis?
3: Who is NOT getting a total hip?
4: Who is NOT getting angioplasty?
5: Who is NOT getting their scooter or lift chair?
6: Who is NOT getting home health?
7: Who is NOT getting resuscitated?
8: Who is NOT getting obesity surgery?
9: Who is NOT getting an ambulance ride home?
These questions and others like them must be answered before you can ration out the rest of available care.

maggie mahar
Guest

Thanks for your comments– Rbar & Joe– I agree about standards for auto safety. Do you remember how long it took for us to even get seat belts? Other countries do regulate industries that deal in necessities or near-necessities (which, in many areas of this country a car is) and affect the safety of the population. And rbar– The legislation in Congress that would creat ea “Comparative Effectiveness Institute” would determine which treatments are most effective. Then, I hope that Medicare (and other insurers) will begin setting co-pays based on what is most effective, from no-copay (for the medically most… Read more »

rbar
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rbar

Believe it or not, Joe, a lot of industrialized countries actually do set minimum standards for car safety (in Germany, for instance, there are biannual safety reviews). I do think that (even) in the US, laws forbid you to operate a car without working brakes or head lights, and many states require helmets for motorcyclists. In analogy to that, my belief is, as a physician: there has to be a reasonable minimum standard for everyone(the wealthy will always have some means to boost their healthcare one way or the other). If I was king of the US (I know, this… Read more »

Joe
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Joe

Maggie- rhetorical question: how is it our society allows the wealthy to drive cars with safety features the poor cannot afford? It seems disgusting this is allowed to go on— we know that motor vehicle deaths are a prime cause of death in ages 18-44— the same group that is the most uninsured. If we were a country that actually cared about our people, we would mandate that a safety feature on one car must be on all cars. Why can’t the government just subsidize the extra cost? We all need cars, if we do not live in a city… Read more »

Peter
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Peter

One change that would stop the push from manufacturers would be to ban ads for drugs and medical devices. Let your doc determine what is medially needed, isn’t that why we trained them?

MikeC
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MikeC

The idea that we would spend less because the newly covered population would get preventative care, doesn’t hold true. First, because they have already forgone the preventative care and are ready to consume a great deal of healthcare. Second, because the majority of the current covered populations don’t seek preventative care. Just because you have coverage, you probably won’t go in for an annual physicial, etc. because if you aren’t feeling sick you don’t want to spend the co-payment or deductible. No incentive to use preventative medical care, even taking vitamins, exercising, or loosing weight. And often the marginally effective… Read more »

Maggie Mahar
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Mark–
Thanks very much for a thoughtful comment.
Right now, our system is set up to benefit those who
profit from it. We need a patient-center system.
That means paying for treatments that benefit patients–and refusing to pay for treatments that are no better than (and often riskier) than the much less expensive treatments that the new products and services are trying to replace.

Mark
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Mark

The right question! I think that this is the core issue when people propose ‘universal health care’ or ‘health care as a right’. People worry about public funding of cosmetic surgery, genomic based treatments, lifestyle diseases, etc. The answer is simple; and it is complex. First, the simple answer… ‘as much health care as we can afford’. Q: How much is that? A: X dollars Q: But that’s rationing! A: Yes Q: That’s communistic, socialistic, immoral, etc.! A: Our current system is rationing based on ability to pay, not individual need and not on the value of the treatment. Our… Read more »