My pal and co-author of Power Over Pain, Dr. Eric Chevlen, has a very interesting piece in the On The Square feature here at First Things. Eric is a deep thinker and a man of tremendous integrity, intellectual as well as personal. He writes at length here–there is a reason they don’t call him Dr. Soundbite–about health care rationing. I can’t do justice to the piece in a blog entry and I urge you all to read the whole thing. But here is an overview:
First, he provocatively denies that health care is a “right.” From his column:
It’s a mistake to think of health care as a right. It is not a right; it is a good. Freedom of speech, by contrast, is a right, as is freedom of religious belief. They are privileges that inure to individuals as a consequence of the primordial right, free will. That is why we see them as inalienable. The exercise of these rights does not depend on any action of government, but rather on its inaction. Government may not legitimately interfere with their exercise, but nothing mandates that the government provide us with printing press or chapel.
Health care is different. It is more akin to the other goods which sustain life: food, clothing, and shelter. A well-ordered society exists to protect its members from the unlawful taking of life, and is structured to facilitate its members’ acquisition of these goods.
That makes sense to me. And I think it means that while government has an absolute duty to protect rights, it has far less of an obligation to provide citizens with goods. And when it does, there can be reasonable limits placed on what it provides.
Traditionally, Eric says we have distributed health care based on wealth or ability to pay. I would add that to soften the inequities of such a system, we have long had a very robust tradition of providing charity care–that still exists–for those who could not pay. Indeed, physicians were once expected to provide charity care as part of their professional obligation to society. Many still do.
Eric then explains that health care must be rationed because there is not enough to go around. I disagree with that, by which I do not meant that everyone can have whatever health care they want, but that I disagree it is “rationing” when marketplace exigencies are such that certain levels of care are available for some, but not for others. In those cases, no one is particularly targeted. In contrast, with explicit government rationing plans, people would be put into invidious categories such as age and quality of life, as well as being granted care based on purely political considerations (the diseases with strong political advocacy groups would not be rationed). To me, that’s a whole different kettle of fish, although that may be more a matter of semantics than substance.
In the heart of his piece, Eric describes his work as a consultant for a major insurance company:
I am a consultant for one of the largest private health care insurers in the United States. Because chemotherapy agents are among the most expensive medicines that can be prescribed by a physician, the company wanted an experienced medical oncologist to help manage that expensive resource. When I first accepted the position, I had been worried that I might be pressured to make coverage decisions based on the cost of the medication. I wondered if I would be mensch enough to stand up to such pressure. To my relief, I have never been subjected to that kind of pressure. The pressure I have felt is quite a different one. My supervisors have frequently adjured me of the importance of being consistent in decision making. Since all the members of the health plan are paying premiums for the same insurance, they must all receive equal consideration. The only way to achieve that is by adhering to explicit policies based on sound medical evidence of medical necessity. Medical necessity is our touchstone. It is, frankly, the criterion by which we ration health care. If a service is medically necessary, it is covered. Otherwise, it is not.
The conundrum is surely obvious: What do we mean by medical necessity? What are the criteria of determining medical necessity—and who decides?
This is why I believe in a strong tort system to keep insurance companies honest (a different matter than medical malpractice litigation ), to ensure that those decisions are medically, and not financially, based.
Eric concludes by hooting at the claim by Obamacare supporters that the plan will not ration:
To claim that Congress will devise a new federal health care plan that will not involve rationing is like claiming that it will invent a triangle that doesn’t have three sides. Currently, within the private sector of health care, we have a large number of private insurance companies vying for the business of their customers. They ration health care on the basis of evidence-based medical necessity. The Obama health plan, the details of which are still being worked out, will also ration health care. The alternative to that is an accelerated escalation of aggregate health care costs. But the single-payer system to which Obama’s plan will lead will have no competitor and no pressing financial incentive to please its customers. No competitor for the single payer means no alternative for the patient. We can reasonably expect that a single-payer system of rationing will be largely implicit rather than explicit, and governed as much by cost and political considerations as by medical evidence. Such a system would likely combine the fiscal responsibility of the Postal Service, the customer friendliness of the Bureau of Motor Vehicles, and the smooth efficiency of the Immigration and Naturalization Service.
In other words, rationing by government will be far more jackbooted than the cost containment engaged in by insurance companies. You can’t sue the government unless it agrees to be sued. Government administrative appeals seem designed to make you give up in frustration. I think Eric is saying is that we are better off with a robust private sector vying for our business–to which I add, a system leavened by robust patient advocacy and regulatory oversight—than being straitjacketed into a one size fits all public option that would eventually sap all life out of private health insurance, and result in the kind of disaster we see in the UK.
I believe in a mixed system, but overall, I have to reluctantly agree with Eric’s conclusion that the heart and soul of our health care financing system should be based on private sector distribution, with a safety net to help those who can’t obtain insurance and to take the weight of catastrophic conditions. And when you think about it, I guess that is a lot of what the Obamacare debate is all about.
August 30th, 2009 | 10:41 pm
[...] View original post here: “Confessions of a Health Care Rationer” » Secondhand Smoke | A … [...]
August 30th, 2009 | 10:58 pm
Dear Mr Smith,
Dr Chevlen has a lot of interesting things to say in his article, and I applaud his willingness to roll up his sleeves and actually participate in the process, but he needs to go back and re-take Economics 101.
The market’s allocation of things and services that are for sale by enabling buyers and sellers to adjust their prices is not rationing.
Nor are rationing, the decisions of insurers as to whether this or that particular item of care should be reimbursed according to the terms of the contracts they have established with their policyholders.
Rationing occurs when a coercive authority, i.e. a government (whose decisions are enforced by the threat of violence), allocates a particular good or service according to bureaucratic rules.
Rationing is an entirely different kettle of fish.
Moreover, I wonder why the “safety net” has to be a government-controlled entity, paid for by taxes confiscated from the people, again by the threat of imprisonment and violence. Why can a civil society not ensure that even the destitute receive good, compassionate, humane medical care entirely through the actions of voluntary, eleemysonary, and even (gasp!) faith-based institutions, supported by the free will and accord of those who are moved to heed their Creator’s injunctions?
August 31st, 2009 | 12:05 am
[...] post: “Confessions of a Health Care Rationer” » Secondhand Smoke | A … Tags: business, conservative, contact, contracts, culture, exercise, find-us, government, health, [...]
August 31st, 2009 | 12:13 am
[...] is the original: “Confessions of a Health Care Rationer” » Secondhand Smoke | A … Share and [...]
August 31st, 2009 | 12:36 am
“Medical necessity” isn’t all it’s cracked up to be. I speak from direct experience as a cancer patient and spouse of a heart patient. “protocols” for these two types of diseases are constantly changing with new research coming out every day. Right now, if you have decent insurance and good access (you live in a major city that has well trained specialists who keep up) what treatments they will suggest to you and from which you will have to choose may vary significant during any six month period. During the time my spouse went from failed stents to heart surgery, there were 3 or 4 different kinds of stents that were “state of the art” and supposed to have better outcomes. This is called progress. If we move to a government controlled, rationed system, I would expect that research would slow down and that adoption of changes to the protocols would also slow down considerably. It will be especially frustrating if research tells us one thing and we have to wait for government to allow it.
August 31st, 2009 | 12:48 am
[...] View post: “Confessions of a Health Care Rationer” » Secondhand Smoke | A … [...]
August 31st, 2009 | 12:53 am
Punditarian: I think you nailed it when you said that rationing is “occurs when a coercive authority, i.e. a government (whose decisions are enforced by the threat of violence), allocates a particular good or service according to bureaucratic rules.” That is precisely how Obamacare would lead to rationing, and why cost containment in health insurance isn’t rationing.
August 31st, 2009 | 1:08 am
[...] Read the original: “Confessions of a Health Care Rationer” » Secondhand Smoke | A … [...]
August 31st, 2009 | 1:42 am
[...] Read the original here: “Confessions of a Health Care Rationer” » Secondhand Smoke | A … [...]
August 31st, 2009 | 2:12 am
[...] the original: “Confessions of a Health Care Rationer” » Secondhand Smoke | A … :better-chance, big-surprise-, call-him, care-rationing-, false-false, Health, [...]
August 31st, 2009 | 4:29 am
[...] Read the rest here: “Confessions of a Health Care Rationer” » Secondhand Smoke | A … [...]
August 31st, 2009 | 6:00 am
Dear Mr Smith,
Thank you for your kind comment and agreement. Now I hope that your readers will see why we should avoid using the term “rationing” indiscriminately.
To call the actions of private insurance companies “rationing” or to call the effects of a free market “rationing” is really an exercise in rhetorical legerdemain and misdirection, with the intention of obscuring the fact that socialized medicine will bring with it real rationing, rather than situations which are often disingenuously described as “rationing.” If we already have “rationing” via the free market (e.g. the so-called “rationing by price” — which is not rationing!) then the rationing by Obama’s Health Czar really won’t be so bad, will it?
It will . . . .
August 31st, 2009 | 10:22 am
How totally unrealistic: a tort system that allows Mr. Joe average to go up against multi-billion dollar insurance companies that have hundreds of lawyers on retainer. Surely he can’t be serious.
August 31st, 2009 | 12:01 pm
Sorry, Wesley, but I do not believe for one second that Dr. Chevlin’s experience is universal. Nor am I convinced that his decision-making methods guarantee a fair assessment of medical necessity.
As pointed out above, even if there was absolutely no influence of aggressive financial protection for the insurance company, there would be te problem of medical research and protocols for practicing medicine– WHICH CHANGE CONSTANTLY.
Education and medicine have both become very faddish; that is, they are NOT driven by comprehensive, evidence-based innovations. They are largely driven by marketing of technology and the use of convenience practices. When something “seems” to work, expecially with a big-time item like cancer or childbirth, it is often put into use without a lot of testing. And no, that is not illegal; if a drug or technology has been approved for one use it is usualy able to be used for ANY use so long as a large enough number of doctors think its fine.
I agree with most of his arguments, but I am sorry to say that the whole process of determining medical necessuity is influenced by the non-practice of evidence-based medicine.
August 31st, 2009 | 12:04 pm
All are correct in saying health care is not a right, but it’s not quite like “goods” or even “food, clothing, or shelter” — it’s shelter, pure and simple. It’s protection from hazard, either preventively or after the fact.
If you think of it that way a lot of this discussion makes more sense. For instance, everybody has a reasonable expectation of a basic level of police protection. If you need or desire protection beyond that basic level, you’re on your own; you hire a private security service, or buy a German Shepherd, or build a fence, whatever. But anybody who legitimately needs a cop can call one and expect a response.
Most if not all of the “advanced” countries, except for us, take the same approach to health care. It’s reasonable to expect some level of basic protection to be available regardless of economic status. It’s reasonable to expect to pay if you want a higher level of protection. That’s where we need to get to.
August 31st, 2009 | 12:05 pm
Yes, sure, but how is Mr. Joe Average going to be able to go up against the full force and credit of the United States Government?
August 31st, 2009 | 12:58 pm
padraig,
Thanks for your insightful comment, which allows us to dig somewhat deeper into the mess of socialized medicine.
The difference between police protection and private security protection is far more than a difference in degree.
According to law, and in practice, the police have absolutely ZERO responsibility to protect any particular individual from any particular criminal act. Their job is to protect the community, by creating a milieu in which most crimes are eventually solved and most criminals eventually punished/rehabilitated/executed — as fits the crime.
But they have no responsbility at all to be there to protect you from a crime that is being committed.
That’s your job, and the job of private security, if you hire them for that purpose.
The discussion of socialized medicine, and of health care in general, has become muddied by a confusion between the provision of an individual’s medical care on the one hand, and the measures that are suitable to advance the “public health” on the other hand. This is something about which I could write a book. It is a confusion that is widespread in the medical profession, and it goes very deep.
An example: We have come to accept only epidemiological evidence as proof that any given medical intervention “works.” That is, if you want to prove that a drug works, you conduct a double-blind, randomized, prospective, placebo-controlled trial, and determine if the population that received the drug did better than the population that received the placebo. It is of course an obvious fallacy to assume that an individual in either population’s risk is equal to the risk of that population as a whole, but that’s how we do it. What we have are population data, and evidence of what works for a population, but that might not have anything to do with an individual’s actual results.
All of the measures used in most discussions of health care reform — life expectancy, infant mortality, etc — are population-based, epidemiological data. They don’t really inform us what it is like for an individual to get medical care for a particular medical problem, nor do they necessarily predict what the results of that care will be for that particular individual.
The arguments about health care reform would make more sense if they were about public health measures — but they are not. If the government takes over medical care, the results for individuals will be profound, and they will not be for the better. Eventually, public health measures will suffer, too. But individuals will feel the brunt first.
To return to your analogy, how many police there are in your community, and how they operate, may eventually influence your risk of being victimized by a criminal. But changing those factors would not be the same as the government taking control of your personal ability to defend yourself from crime by locking your doors, arming yourself, or hiring private security guards. That’s what socialized medicine means, the inability for everyone except the well-connected, well-healed nomenklatura to make their own decisions regarding their own medical treatment.
August 31st, 2009 | 4:13 pm
[...] don’t call him Dr. Soundbite–about health care rationing. Go here to see the original: “Confessions of a Health Care Rationer” » Secondhand Smoke | A … Categories: Health Tags: celebrity-births, Health, health products, length-here, none-, [...]
August 31st, 2009 | 5:09 pm
A strong tort system to keep insurance companies honest? KEEP them honest? They aren’t honest in the first place, and they can’t be made honest; a leopard doesn’t change its spots. Furthermore it’s SUPPOSED to be ABOUT medical malpractice! Which tort action can’t combat, but only makes MORE prevalent, when it’s directed at the insurance companies, in doing which it plays right into the hands of the insurance companies. The insurance companies don’t belong in medicine in the first place. They have to be gotten rid of, and tort actions that are not even directed at them can’t accomplish that. Tip of the hat to you, History Writer.
August 31st, 2009 | 5:17 pm
“According to law, and in practice, the police have absolutely ZERO responsibility to protect any particular individual from any particular criminal act. Their job is to protect the community, by creating a milieu in which most crimes are eventually solved and most criminals eventually punished/rehabilitated/executed — as fits the crime.”
You lost your argument right there.
If a policeman is informed of a crime in progress, they absolutely have an obligation to attempt to stop it. According to your logic, if they come across a man beating his wife to death, their only obligation is to put the guy in jail afterwards.
Police also actively engage in prevention, although that’s better handled by societal measures like education. If your point is that the police are not responsible for crimes they fail to prevent, well, of course not.
And having police around does not prevent me from taking steps to ensure my own security, and this “socialized medicine” you demonize, even if it were the actual goal of this administration, would not prevent you from taking steps to ensure your own health.
August 31st, 2009 | 5:17 pm
To clarify, the tort actions aren’t brought against the insurance companies, in form. As long as the insurance companies exist, everything is going to keep getting worse and worse, in medicine and in society. They’re a security blanket, a lottery, a system in which everyone has to pay and others pay for others, a fear-based industry, and a form of socialism, and look what road we’re going down now. In the same society where illegal and legal drugs are rife and parents end every statement to their kids with “ok?” and can’t even get them to tie their shoes. Because people were willing to be weak and lazy and dependent. Might as well try to straighten out a drug dealer or an addict as try to “keep” the insurance companies honest. and doctors have lost their ethics along with insurance companies getting involved with medicine. Doesn’t anybody SEE this? It’s SIMPLE!
August 31st, 2009 | 7:38 pm
Thanks Ianthe. Imagine keeping an insurance company honest?? Think AIG.
August 31st, 2009 | 8:25 pm
Padraig:
I think Punditarian’s point stands. If I am murdered, my next of kin can’t sue law enforcement for not preventing the crime. The duty of law enforcement is to protect citizens, but through a combination of response to crime, investigation of crime that has occurred, and the incarceration of criminals.
Likewise, the government has key public health responsibilities, such as ensuring food safety, certifying new drugs, investigating questionable medical treatments, and (most important) promoting sanitation through waste treatment, clean water, and garbage collection.
However, when it comes to insurance, what makes anyone think that a public option would be any better than the group insurance plans currently available? The pressure to cut costs would still be there – in fact, given the terrifying national debt, it might be stronger than ever. The House bill already claims there will be hundreds of billions of dollars in cost savings wrung from Medicare and Medicaid. Also, it would be even harder for a wronged patient to get satisfaction from a public plan making its own rules than a private plan.
There are improvements that could be made to our current system, surely (I’d like to see insurance decoupled from employers), but does this plan address them well? I’m convinced it will make things worse rather than better.
August 31st, 2009 | 9:47 pm
padraig,
Forgive me for seconding SparcVark, but you are mistaken about the facts of this matter. The courts have repeatedly held that the police have no obligation to prevent any particular crime. Of course, if they happen to be there just when an abusive husband hauls off on his wife, of course they will do something about it. But how often can that be expected to happen? By the time the 911 operator sends them to your house, and they arrive, you may be already dead. And they have no liability. Our gracious host is an attorney, and he must know about this aspect of the law. To quote “legalmatch dot com” for what it may be worth: “Police generally only have a duty to protect the public at large. So while police can be held liable for failing to respond to a wild shootout in a public subway, they may not be held liable for someone who gets injured while their car is robbed. In other words, police have no duty to protect individual citizens from injury by others.”
To return to our mutton, a public health agency analogously has no responsibility to protect you from any particular disease, nor treat you for any particular disease.
But your doctor does; and the courts will hold your doctor responsible for adhering to generally accepted standards of care in personally taking care of you. That’s the difference between public health measures and medical care.
Analogous to the police, roads department, and other public works, a government might legitimately be used to advance public health initiatives by the citizens from whose consent it derives its just powers. But taking care of individuals and their medical problems is not something that can safely be entrusted to the State.
One reason for that is that the State generally assumes monopolistic control over whatever areas of life it determines to be within its power. Thus, to continue our police analogy, the police power is the exclusive preserve of the State. You may employ private guards, but your guards will not have the power to arrest, detain, or imprison those whom they may deem a hazard to you. You may not set up your own private courts and private jails. Nor may you perform your own road repairs or set up traffic signs that suit your ideas of where motorists should stop or turn.
If you concede control over individual medical care to the State, you will lose your ability to obtain the medical care you may want outside of the State’s system. To a degree, that situation already obtains, since in order to practice medicine legally, a doctor must be licensed by the State. In our country, the licensing function is mainly a record-keeping function, in that the State issues licenses to those doctors who can show that they have been adequately educated and trained, very often in private institutions. The specialty boards are also private corporations. But under socialized medicine, all of these functions will come increasingly under State domination. Those who are selected to become doctors will be those the State wants to train, and the places where they practice and the ways they practice will be controlled by the bureaucracy. I don’t think you would like it very much.
September 1st, 2009 | 11:47 am
Punditarian: “The courts have repeatedly held that the police have no obligation to prevent any particular crime.”
As I pointed out myself.
” Of course, if they happen to be there just when an abusive husband hauls off on his wife, of course they will do something about it. But how often can that be expected to happen?”
You need to leave the library, turn on the TV, and watch some “COPS” reruns.
Links
Blogs
Find Us
Contact