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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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.
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 effective treatment for patients meeting a certain profile) to a very high co-pay for less effective treatments–while also making information about the true risks of many tests and treatments public. . .
Peter– I agree about banning ads. (New Zealand is the only other country that allows these ads.)
But I dont’ think we want to leave figuring out which
treatments are most effective to individual doctors. No one can keep up with all of the research, even in their own specialty. In addition, there are many financial incentives–from fee-for-service payments if you do more, to consulting fees from manufacturers–that can bias a doctors’ decision, even if only unconsciously.
That’s why we want a national board–as Rbar suggests–made up of people who have no financial interest in t he outcome, setting up guidelines (not rules) on most effective treatments for particular sets of patients, and making those guidelines public.
Mike C– Yes, as we cover more people we will spend more.
This is not a reason not to cover them, but it is a reason to make sure that our coverage is rational–that it is based on medical evidence of what works and what doesn’t, rather than doctors’ druthers, or the patient or family thinking that they want X or Y.
IN the case of seriously ill patients, it’s particularly important to have palliative care specialists who can explain risks, side effects and benefits to patient and family. Palliative care speciailists are trained to do this in a way that engages the patient in the decision-making, and calms the family.
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 is a rather unlikely scenario), I would create a board (consisting of specialty and nonspecialty physicians as well as nonphysician members) within CMS that would determine, based on the best evidence, which treatments deliver a reasonable bang for the buck, and which diagnostic tests can be restricted based on simple, enforceable guidelines (e.g. brain MRIs for typical migraine headaches).
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 with functioning public transit.
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?
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 tests and treatments, especially for terminal patients or those with a chronic condition, are requested by patients or their advocates. Patient centered? Technology centered? Or manufacturer promotion?
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.
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 country currently spends 2x to 3x as much per person as other developed countries, all of whom provide better care and as a result have better basic health indicators. Even Cuba has equal or better health indicators than the U.S.
The ‘free market’ for health care in the U.S. is very successful at producing spectacular profits for everyone involved and a dismal failure at providing goods and services that improve health. This is a profound market failure.
Q: How do we ration?
A: We need adult supervision. We need regulation. We need the government deciding which services are useful and beneficial and cost efficient.
I know this is an extremely unpopular message and I expect that everyone who is making money in the current system will attack it and patients will also attack it because they will (wrongly) perceive that they won’t get needed services. They will get needed services. They won’t get every unproven test and treatment. If they want to spend their discretionary income on unnecessary tests and unproven treatments and concierge medical care, that’s fine. Just don’t expect the taxpayer to fund it.
Welcome to the real world. This is the way the rest of the world works. The party on Wall street is over. It is time to end the party that we call ‘U.S. Health Care’. It too is a house of cards that is generating obscene profits while providing services of dubious value.