How Would You Ration Health Care?
June 30th, 2009
As the debate over health care reform heats up in Washington, the rhetoric around health care rationing grows more vitriolic. Conservative commentators, such as those writing op-eds for the Wall Street Journal, paint a frightening picture of the world under “Obama-Care,” a world where we would all stand in long lines to get whatever care the state deems reasonable. At the other extreme are the advocates for a massive healthcare overhaul who insist that a single-payer system would end the waste and inefficiencies now rife in our present system, leaving more than enough money to provide optimal care to all the people, all the time.
Let’s park our ideologies at the door and talk facts for the moment. Fact number one: The United States rations health care now, and anyone who doesn’t think that’s true has never come into contact with the medical system–or is very, very rich. But we ration on an ad hoc basis, with little to no honesty around the process. Has your insurer or doctor ever used the word “ration” when discussing the reasons why you should or shouldn’t have a certain procedure? I didn’t think so.
So let me ask you: How should we ration?
First, let’s look at how the U.S. rations today. We start by limiting access to health care for the 40 million to 47 million Americans who do not have insurance. Many people insist that these uninsured do have access to high quality healthcare, in an emergency room or wherever; they just don’t pay for it. Not true. Study after study has found that the uninsured get sicker, die earlier and get lower quality treatment than the insured, precisely because they can’t afford to pay. From an Urban Institute report last year:
In 2002, the Institute of Medicine (IOM) estimated that 18,000 Americans died in 2000 because they were uninsured. Since then, the number of uninsured has grown. Based on the IOM’s methodology and subsequent Census Bureau estimates of insurance coverage, 137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006.
Other researchers have estimated that the death rate could be reduced by 5% to 15% if the uninsured had the same access to care as those with coverage.
Those of us who are insured don’t have to worry, though, right? Well, earlier this month three insurance executives testified before Congress that their companies routinely deny coverage to policy holders with pre-existing conditions, a practice called rescission, and they have no intention of stopping. From the LA Times:
An investigation by the House Subcommittee on Oversight and Investigations showed that health insurers WellPoint Inc., UnitedHealth Group and Assurant Inc. canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period. It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.
For a view from inside the rescission process, read the Congressional testimony of Wendell Potter, former insurance industry executive:
My name is Wendell Potter and for 20 years, I worked as a senior executive at health insurance companies, and I saw how they confuse their customers and dump the sick – all so they can satisfy their Wall Street investors. I know from personal experience that members of Congress and the public have good reason to question the honesty and trustworthiness of the insurance industry. Insurers make promises they have no intention of keeping, they flout regulations designed to protect consumers, and they make it nearly impossible to understand—or even to obtain—information we need.
There are other ways we ration. We limit the number of doctors that can be trained each year, and effectively limit the numbers of primary care physicians by reimbursing them at much lower rates than specialists, thus encouraging medical students to avoid that path. The result is doctor shortages and long wait times for appointments, often longer than Europeans and Canadians, the ones with universal health care, have to put up with.
Insurers also typically do not pay for preventive care, which might save money in the long run but not in the short term. And as New York Times economics columnist David Leonhardt points out, by allocating 18% of our gross domestic policy to health care we are devoting fewer dollars to salaries, savings and other social goods like college loans.
A 10% increase in health premiums leads to a 2.3% decline in inflation-adjusted pay. Victor Fuchs, a Stanford economist, and Ezekiel Emanuel, an oncologist now in the Obama administration, published an article in The Journal of the American Medical Association last year that nicely captured the tradeoff. When health costs have grown fastest over the last two decades, they wrote, wages have grown slowest, and vice versa. So when middle-class families complain about being stretched thin, they’re really complaining about rationing. Our expensive, inefficient health care system is eating up money that could otherwise pay for a mortgage, a car, a vacation or college tuition.
Then there is the way the U.S. chooses to spend the $2.3 trillion it will allocate for health care this year. We have decided that our top priority is to help the dying–studies estimate that 10% to 12% of U.S. health dollars are spent on end-of-life care. About 25% of Medicare’s budget is spent on patients in their final year of life, and almost half that amount is spent on the final 30 days.
That makes little sense to me, and I speak from experience. When my grandmother was a frail 96-year-old, she fell and broke a hip. Despite our family’s better judgment, doctors talked us into hip replacement surgery, from which she never fully recovered. She did not walk again, she quickly fell into dementia, and died with six months. I doubt very much she would have had that wasteful operation in a European nation. Then there was my mother, who died of an asthma attack at age 64. But first, the hospital was able to revive her enough to put her on a ventilator. Although she had a living will, and her family wanted the machinery disconnected, she lived in a deep coma for another five weeks, unresponsive, essentially a vegetable. I cannot imagine the financial cost, and I am all too aware of the emotional cost. Again, I do not think that would happen in a European nation. But take a look at England, home of “socialized medicine.” My husband died of a brain tumor in London despite the uniformly excellent care he received, all free thanks to the National Health Service. In his final month cancer was found in his liver, but the doctors felt there was no point in putting him through any more painful treatments. We agreed and he died peacefully in hospice.
So, how would you like to die, and live? Should our health care dollars be spent on prenatal care or end-of-life care? How about preventive care, mental health care, dental care–how much are they worth? Should we insure everyone, or just those who can afford the premiums? Be upfront about rationing, or continue on an ad hoc basis?
It’s time for an honest and open debate, don’t you think?
For some great insights into how America rations, bookmark The Covert Rationing Blog by DrRich, a former cardiologist and medical professor who now works as a consultant.
Also, if you want to learn about one model under consideration for lowering health care costs, read my story on patient-centered medical homes: The Family Doctor: A Remedy For health Care Costs?
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