Death Panels

One of our medical students, Vishal Khetpal, has a column in Slate about the "R" word, that is "rationing" of health care. He says we need to do it.

If you've been viewing this space for many years, you know that I used to talk about this quite a lot. One of the most popular tropes of right-wing opponents of government-provided health care, whether we're talking single payer or kludgier methods, is that it will mean "rationing." The horror! The horror!

That was of course supposed to be the single most evilest thing about the Affordable Care Act, that it included death panels that would supposedly decide who would get the privilege of meeting Jesus in the sky. Obviously, it doesn't have any such provision. Nor does it have any rationing, however conceived or implemented. On the contrary, prior to the ACA most policies had lifetime dollar limits. But now they don't. To quote health benefits consultant Ryan Seimers:

On the eve of the ACA, most plans still had a lifetime dollar limit . . . often at $1 million or $2 million. The actual occurrence of a $1 million claimant was very rare. [But now] "No longer did hospitals have to "tap the brakes" as costly care approached $1 million. Specialty drug developers (and their investors) were provided a limitless runway to fund therapies . . . potentially costing $100,00s per year.

He cites surveys showing various insurers facing increases in claims above $1 million of three times or more. You might want to read the whole slideshow to understand the issue.

So there were all sorts of rationing before the ACA -- including annual and lifetime limits. And of course, denial of insurance entirely to people who would likely be expensive. And limited benefit packages -- no vision, no dental, no behavioral health, that sort of thing. There wasn't a group of people in black robes sitting around a table deciding that Pemberton P. Throckmorton of Nutley, New Jersey, must be denied medical treatment. But there were plenty of reasons why Pemberton might be shit out of luck.

The fact is, we condemn people to death in this country every day because they can't afford medical care. The difference now is that thanks to the ACA, we do it to fewer of them. And if we had universal, comprehensive single payer national health care, we'd do it to even fewer.

But -- and this is the part that people have trouble with -- it would be a bit more obvious when it did happen. And it would have to happen. Resources are finite. It is always possible to find ways to spend more money to give desperately sick people a small chance at extending their very unpleasant life by a few days. And there are other demands on society's resources, including investing in improving population health and reducing the prevalence of disease. Health care could easily devour the economy if we let it.

So no, we don't need any panels to rule specifically on the individual fate of Pemberton Throckmorton. But we do need to decide that there are some treatments that just aren't worth the cost. If you're as rich as the Koch brothers, you can still pay for them yourself if you want to, but as a taxpayer, you need to set limits. That's just the way the world works. But as long as we're doing it -- and we are, right now, today -- we should find ways of doing it more fairly and transparently.