Map of life expectancy at birth from Global Education Project.

Thursday, August 13, 2009

The wonkish truth behind the death panels

It is a plain fact that there is absolutely nothing in any of the health care reform proposals currently moving in either chamber of Congress which in any way addresses limiting the use of approved drugs or procedures or forcing doctors and patients to choose one over another. Although as we have noted Jim Rutenberg of the New York Times considers charges that the legislation would impose rationing and euthanization to be "questionable," these assertions are in fact false. Of course reporters are not allowed to say that Republicans are lying. They can only say that about Al Gore.

Nevertheless, everybody who studies health care seriously knows full well that we do, in fact, need to have rational controls over the use of medical resources, because if we don't, the irrationality of the way resources are allocated will just continue to grow worse and worse. The problem is that the public is simply unable to confront reality in this area, and meaningful action has become politically impossible. There are four basic concepts that I think people need to understand in order to make sense of the problem. These are the fact of scarcity; the rule of rescue; comparative effectiveness; and cost effectiveness.

Uwe Reinhardt, the eminent health economist, writes:

The . . . opponents of cost-effectiveness analysis [include] individuals who sincerely believe that health and life are “priceless” — for them, cost should never be allowed to enter clinical decisions. It is an utterly romantic notion and, if I may say so, also an utterly a silly one. No society could ever act consistently on such a credo.


Reinhardt is invoking the fact of scarcity. The fact is that none of the people who are howling about euthanasia at the town hall meetings actually believes that life is "priceless." They think they believe that, but they don't. There are thousands of children dying every day whose lives they could save for five dollars apiece. Alright, they aren't thinking about those kids because they mostly have dark skins and live in faraway places, so let's talk about what they are thinking.

The Rule of Rescue is a moral intuition that most people have, which essentially says that no effort should be spared to save people in dire circumstances. We are emotionally drawn to these situations -- the miners trapped underground, the earthquake victims trapped in the rubble. But if you stop to think about it, the resources which are actually allocated to these situations are limited. If life were infinitely precious, nobody would ever go down in a mine in the first place. Certainly if they did, far more would be spent on safety than is spent in reality, and the drilling equipment needed to rescue them in the event of a collapse would be pre-positioned. That we accept peril in exchange for saving money is a commonplace of everyday life.

Let us suppose you got a survey in the mail and one of the questions was whether you agree or disagree with the statement that "Every patient should have access to effective treatments regardless of the cost." I think most people would agree. Then suppose you were given a specific case to think about. There's a cancer patient, and there's a treatment that costs $200,000. Do you think the person should be given that treatment if it will extend his or her life by 1 day? How about 1 week? 4 months? A year? I don't know what amount of additional life span you think justifies spending $200,000, but I do know that hardly anyone thinks it is worth it for 1 day. If I bumped the money up to $1 million, obviously, people would tend to need longer added life to make it seem worthwhile -- especially since we're presumably talking about somebody who is very sick with cancer and probably has a very poor quality of life to begin with. So there you have it -- you do put a monetary value on life.

And if you say you don't, then why are you drinking that double tall latte? You could be donating that money to save somebody's life.

Obviously insurance companies can't charge an infinite amount for premiums, they have to keep their product cheap enough that employers and the occasional individual will buy it. We know all the bad things they do -- kick off people with pre-existing conditions, drop people when they get sick. But they also limit what they will pay for, short of dropping you entirely. People don't want to pay infinite taxes for Medicare and Medicaid either. And guess what? If we did pay everything we have to keep very sick people alive for as long as possible, we would have a lot more sick people because we wouldn't have adequate food, clothing and shelter.

So we have no choice but to decide that when it comes to health care, enough is enough. Life may be priceless in some sense, but not in the financial sense. We can only do so much.

The president has talked about Comparative Effectiveness Research, and as a matter of fact he's gotten congress to pay for it through the stimulus legislation. But Comparative Effectiveness Research does not consider cost. It just compares one treatment to another to see which one works better. Drug and medical device manufacturers, and some medical specialists, don't like this because it makes it harder for them to sell stuff that doesn't work very well, but why hordes of screaming right wing Christians are opposed to it is very hard to understand.

Cost effectiveness analysis, on the other hand, which does consider costs, has not even been mentioned by the president nor is it incorporated in any legislation, although it is used in the United Kingdom and Canada routinely. They manage to live longer than we do even though they don't consider human life to be priceless. The reason is precisely because they put a price on it, which enables them to make rational decisions -- yes, to ration -- to use the resources they do have as effectively as possible.

Note, however, that they do not consider people's current state of health or disability. Steven Hawking, in spite of having ALS, gets health care. Rather, the consideration is the value added by the treatment. Since Trig Palin is a baby, presumably giving him medical care should he say, get cancer, will add decades to his life. Therefore, cost effectiveness analysis says we should spend a whole lot on him. That he has Down Syndrome is irrelevant. The issue is not the person, but the treatment and what is gained by it, regardless of who is treated.

But it is politically impossible to talk about this in the United States. As a result, we'll just keeping dying sooner than we have to, because we console ourselves with the illusion that we aren't rationing health care.

11 comments:

C. Corax said...

The screeching right wing also HATE the idea of socialist medicine, but they certainly weren't mortgaging their homes to pay for Terry Schiavo's medical bills.

Daniel said...

I appreciate your posts on this issue.

I've been pondering what to do if health care reform fails to deliver. I own a relatively small energy engineering software company. Do I keep providing employer paid insurance for my employees? That just contributes to the status quo and enables irresponsible behavior by politicians and health care wackos. But, a colleague of 30 years who has MS is covered by the policy...

I hope that if we can take one step forward on this issue, even if it is imperfect, that the second step will be easier to take.

Cervantes said...

Well Daniel, all I can say is that if, as an employer, you have access to group coverage, your employee with MS is depending on you because she won't be able to buy coverage on her own. I don't think it would make any sense to drop your insurance as a political statement.

That said, it's just going to keep getting more expensive and you're going to be in more and more of a bind. I wish that small business owners would be more active in backing reform. It's in your interest.

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