Rationing life

One of the objections we often hear to a national health care program is that it will cause health care to be "rationed." Well, yes. Spending on health care under a national health insurance or health care program will not be infinite. Right now, in the U.S., we ration health care -- specifically, on the basis of ability to pay. Some people decide every month whether to buy drugs, eat three meals a day, or heat their homes. Some people are bankrupted by medical bills and lose their homes entirely. And lots of people don't get basic medical care and end up with serious, expensive and completely preventable illnesses that the rest of us end up paying for. Meanwhile, we spend more and more money, and a higher percentage of GNP on health care every year -- without knowing how much good most of it is doing. New technologies and new drugs are introduced constantly, most of them very expensive, and as soon as they are approved -- which only requires that they be shown to have some marginal benefit, such as a few weeks added survival for cancer patients -- they quickly become necessities. We're all paying for them, but are they all worth the cost?

In Britain, where they have fully socialized medicine -- not just national health insurance, but a government-run health service that is available to all citizens -- they set up an organization called NICE -- the National Institute for Health and Clinical Excellence. (I think the H is missing from the acronym not only to make it spell something cute, but also because public health was added to its mandate later, after it had already just been NICE.) NICE evaluates new medical technologies, including drugs, not only for effectiveness, but also for cost-effectiveness. It uses a very open, transparent, and rigorous process in which there is representation of all affected sectors. Check out their web-site, and just click on the link to "Final Appraisal Determination: Cardiovascular Disease: Statins," to find out how it works. If NICE recommends a new treatment, National Health Service bodies have to provide funding for them.

"Ah but," I intuit that you are thinking, "how is this 'cost effectiveness' measured?" Here's where it gets into territory that many people find disturbing. Cost-effectiveness, in a nutshell, means that you know what you are buying with each dollar, and in this case, it's something called a Quality Adjusted Life Year, or QUALY. To measure QUALYs, researchers first surveyed large numbers of people and asked them how much of their life span they would give up in order not to have, say, disabling heart failure or intractable pain. (This procedure may be criticized on various grounds, but if you want to criticize it, you are required to come up with a better idea.) Then they use this information to weight years of life in calcualtions, e.g., two years with a disability might be worth one year in perfect health.

So, NICE generally decides that an intervention is cost-effective if it buys one QUALY for something less than $45,600. (Of course they use British Pounds.) Above that, they are likely to say that it isn't.

But wait! How can you put a price on life? Isn't life infinitely precious? Is NICE saying I should let Grandma die rather than spend $45,601?

Well, kind of -- although that's only if the money will keep her alive for less than one additional year in good health. There are two problems we need to consider:

a) Grandma will die, just like everybody else, no matter how much we spend. It's only a question of when and in what condition.

b) Life might be infinitely precious, but we don't have infinite resources. Every dime we spend on Grandma is coming from somewhere else, which might for example be food for a hungry child or the money for noble missions such as occupying Iraq. These choices have to be made somehow.

At least the kind of work that NICE does makes these choices explicit. Whether Americans, with their Culture of Life and their equally powerful Culture of Entitlement will ever be able to look truth in the face remains to be seen, however.