My son summarized my new situation with typical teenage irreverence: “Gee, Dad, after thirty years of providing health care, your new job is denying it.”
It’s a funny line, of course, if somewhat harsh. I’ll probably let him out of his room in a few weeks. But his quip is largely untrue. Its bite comes from the fact that it’s not entirely untrue.
It’s a strange turn of events, really. After all, I have always been opposed to healthcare rationing. But, then, I have always been opposed to aging, too. I have come to recognize the fundamental similarity between the two. They are simply unavoidable evils (pace Chesterton, Cicero, et al.). The best we can do is to manage them with wisdom and compassion.
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.
But health care differs from these other goods: First, health care is not absolutely essential for all people on a daily basis; second, there is an insufficient supply in this world to meet the demand of those who would have it. There is enough food in the world to feed everyone. Hunger and famine are the result of its inadequate distribution, not its absolute dearth. There are enough garments in the world to clothe everyone, and enough roofs to protect all from the rain. Health care, in contrast, is a far scarcer resource. Descartes once remarked that common sense is the most equitably distributed attribute in the world, because we never see anybody who feels he doesn’t have enough. Health care is not like common sense. We often see people who feel they don’t have enough, or at least can’t get enough at a price they’re willing or able to pay.
Until modern times, health care in the United States was distributed as most goods of life are distributed—according to personal wealth. The rich could afford it, and the poor couldn’t. Most economists would exclude this sort of market allocation as a form of rationing by definition. Nonetheless, market allocation is a form of distributing goods within a society, and when there are not enough of those goods to go around, the end-result in the short term is much the same.
Limiting health care’s availability by the criterion of personal wealth rightly offends our sense of the dignity of the individual. Are the lives of the poor not of the same intrinsic value of those of the wealthy? To be fair, it is rare in the United States that poverty alone prevents the uninsured poor from receiving lifesaving intervention in a healthcare crisis. A poor man having a heart attack is not turned away from the emergency room, nor is the poor woman in labor sent away to have her baby at home. (I am not arguing that such enormities never occur, but the fact that such occurrences remain scandalous and newsworthy is a testament to their rarity.) Yet it is equally undeniable that the poor get a lesser share of the preventive care that can maintain health or of the quotidian care for the less dramatic challenges to their health.
There are two major alternatives to the allocating of health care on the basis of personal wealth. Both involve a large number of individuals agreeing (or having imposed on them) that the amount of health care they receive will not be in strict accord to how much they have paid for it. The cost will be distributed over the healthy as well as the sick, even though the benefit will inure only to those who are ill or who need health care to prevent illness. People accept the certainty of a bearable cost to avoid the risk of an unbearable one. But to the extent that these collective programs sever the connection between paying for health care and receiving it, they generate increased demand for health care. The individual feels that he has already paid for health care. When he is sick, or thinks that he is sick, he feels fully entitled to care with no consideration of cost. After all, he has already paid for it, hasn’t he? Given the limited amount of health care that may be bought with the aggregate funds of the group, this untrammeled demand for it must always result in rationing. This is true whether the collective effort is a private insurance plan or a government program. Rationing is inevitable in all collective health care financing schemes.
Rationing must occur, but it need not be admitted. Denying the truth of rationing is more common in government-run health care schemes than private ones, because the government is reluctant to have the people know this ugly fact. Government-run programs, therefore, are more likely to disguise the rationing. This plausibly deniable form of limiting health care is called implicit healthcare rationing, and it assumes many forms. Rationing by termination occurs when patients are discharged from the hospital earlier than is medically optimal. Rationing by dilution occurs when second-best rather than first-best treatment is provided. Rationing by rejection or redirection involves healthcare providers turning away patients whose care will be inadequately reimbursed. This is commonly seen now in the Medicare and Medicaid programs, because those programs reimburse providers at a rate substantially lower than private insurance plans. Perhaps more common than those forms of rationing is rationing by delay, as exemplified by the outrageous amount of time patients in Canada must wait for hip replacement surgery or colonoscopy. The unifying theme in all these forms of implicit rationing is that, without admitting it, they force some patients to forego medical care that they want and are ostensibly entitled to receive.
Private insurance plans sometimes include an element of implicit rationing, but because they are, at heart, contractual agreements between the insurance company and the insured are more likely to ration health care explicitly. The many pages of the healthcare plan describe what is a covered service, which providers will be reimbursed for services, the duration of coverage, the dollar limit, and so on. The advantage of explicit over implicit rationing is obvious: It gives potential customers of the insurance plan information to use when deciding which insurance plan to buy, and gives them clear expectations of services to be delivered. Implicit rationing, by contrast, may have the sweetness of a promise, but is usually succeeded by the bitterness of a promise broken.
All modern societies ration health care. A wise society considers the options and chooses a method of doing so which best conforms to its values and capabilities. Thus we come to the terrible question we would so very much like to avoid: How shall we ration health care? How shall we explicitly ration it? So noxious a question is this, so offensive in its tacit assumptions and implications, that most politicians and wishful thinkers will deny that we need to address it at all. They will argue that the fundamental problem is one of distribution, not one of unmeetable demand. They will argue, with more enthusiasm than evidence, that an emphasis on preventive care would substantially reduce aggregate demand. Some will say we must reduce the role of government; others will argue that we should augment it. If only we will adopt their plan—they’ll say—waste, fraud, and abuse will be abolished. There will be chicken—or at least chicken soup—in every pot, and a vaccine in every arm. People love honesty, but they hate the truth. To frankly acknowledge and address the ineluctable reality of healthcare rationing is not merely to touch the proverbial third rail of American politics; it is to lie across the tracks in front of the onrushing train.
Come, let us speak of unpleasant things. How is health care to be rationed? Who gets the short end of the stick?
There are several rational approaches. An example of attempted explicit rationing of health care in a government-financed system may be found in Oregon. In 1994 Oregon implemented a program that would expand the number of poor people covered by Medicaid, but explicitly ration the care they receive. Oregon chose to priorate the different services that a patient might conceivably want, ranking them in order of how important the procedures were for maintaining life and promoting health. The legislature determined how much it was willing to spend for the health care of the poor, and then the bureaucrats literally drew a line across the list. All the services above the line would be covered by the state Medicaid plan; all those below would not. Thus, the solons of Oregon determined that treatment of veneral warts would be covered by the Oregon Health Plan; treatment of chronic anal fissures would not.
In practice, this procedure did not prove to be the efficient money-saver its developers envisioned. From the beginning, the list did not exclude procedures that were very expensive in the aggregate. The list needed continual updating and adjusting, often on the basis of nonscientific criteria, since the opinions of the taxpayers (which is a nice way of saying political pressure) had to be considered. In the first six years of the program, costs skyrocketed seventy-seven percent. Eventually, the state had to resort to admitting new enrollees to the insurance program on the basis of a lottery.
The political reality of the Oregon healthcare rationing is that it could be imposed by the taxpayers on the recipients of their largesse only because it was not being imposed on the taxpayers themselves. For government to explicitly ration the health care of those who are actually paying for it may be undoable in a democracy. That explains why healthcare rationing in Medicare and Medicaid is mostly implicit rather than explicit. It is noteworthy and instructive that no other state has followed Oregon’s lead in this approach.
An alternative to explicit government mandated healthcare rationing is rationing by private industry. There is one great advantage that private healthcare rationing has compared with government rationing: competition. In the private marketplace, there will be a number of insurers, each with its own criteria and implementation of rationing. A company which is unreasonable or high-handed in its coverage decisions will find that its unhappy customers soon become its former customers. It’s true that millions of Americans have their healthcare plan chosen for them by their employers. But employees, both as individuals and via unions, certainly have an impact on the choice of company health plans. Also, it must be kept in mind that the management of the company is almost always covered by the same healthcare plans offered to the rank-and-file employees.
While a variety of insurers, prices, and plans are available, the comparative shopper for healthcare insurance is still unlikely to find any insurance that does not have rationing as part of its processes; at best, he may find one whose criteria of rationing are more to his liking. It is to those criteria, the proverbial devilish details, that I now turn.
I am a consultant for one of the largest private healthcare 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?
The meaning of medical necessity is easy to state, if hard to pin down. The definition, part of the contract between the insured and the company, is this: services that a medical practitioner, exercising prudent clinical judgment, would provide to a patient to prevent, diagnose, or treat an illness. The definition further requires that such services be in accordance with generally accepted standards of medical practice, clinically appropriate for the patient, not primarily for the patient’s convenience, and not more costly than similar services likely to yield results which are at least as good.
I don’t suppose that I could come up with a better definition of medically necessary, but it is surely obvious that this definition requires heaping measures of interpretation. What is prudent? What is generally accepted standards? Requiring that services be medically necessary is unavoidable. Defining the terms is equally unavoidable, but the definition often seems tautological, like loopholes within knots all contorted into a grand Möbius band of potential disputation. The insurance company assembles panels of experts from within the company, academia, and private practice to meet regularly to assess the state of the art for a multitude of diseases and procedures. The panels, in turn, create the policies based on the current evidence. As to who implements the policy, who actually decides what is medical necessity on a case-by-case basis—that, too, is easy to answer: I do. I am the healthcare rationer.
I am not the only one, of course. Like any large bureaucracy we have a large, rational, and, yes, occasionally lumbering system of determining medical necessity. It would be wasteful for the insurance company to have professionals at the highest pay level authorize all these decisions. After all, the vast majority of claims are, indeed, for medically necessary services. Therefore, the initial review of claims is done by nurses or pharmacy technicians. They make their decision based on a carefully vetted, evidence-based checklist of criteria. The majority of these initial reviews end in an authorization for the requested service, and are never considered again within the company. It is important to note that the first-line reviewers have the authority to authorize a service, but not to deny it. If the claim for payment fails to pass the checklist, the first-line reviewer does not deny it, but rather passes it on to a higher level review by a physician.
Before I became a consultant to the insurance company, I shared the cynical view of most harried physicians. I believed that, just as luggage at the airport must surely be handled by behind-the-scenes gorillas who jump on the bags in madcap revelry, so medical claims at insurance companies must be handled by high-school dropouts who make their decisions by consulting articles such as “I am Joe’s Prostate” in well-thumbed copies of Reader’s Digest. Not so. The physicians who do the reviews are, for the most part, still in active practice, and, if not leaders in their fields, are clearly several notches above average. Hiring such qualified personnel is not merely a kindness to the insured members of the insurance plan; it is simply good management. If a company makes too many bad decisions, it will suffer in the courtroom, in corporate boardrooms, and on the floor of the stock exchange.
But the fact that good doctors are making decisions for the insurance company does not preclude disagreement between the insurance company and the providers. These providers of the contested medical services are, for the most part, also good doctors. When there is a disagreement between the two, who is right? We return to the conundrum of determining medical necessity.
On its face, one might think that the question of medical necessity is best answered by the physician who is actually taking care of the patient, rather than one who has never met him and is basing his decisions on a limited amount of information. But that will not do. That thought is one of the many illusory ways of denying the inevitability of rationing. To have the providers determine medical necessity is to have no limits at all on expenditures for health care, since all providers at all times believe (or at least claim) that the service they are providing is medically necessary. To have the providers be the arbiters of medical necessity is to abjure rationing altogether. The insurance company that does that will be very popular—very briefly. Then it will either go bankrupt in short order, or sharply adjust its premiums upward to have its income match its hemorrhaging outflow. If premiums rise enough, people will not buy the insurance. The result will quickly be the most generous insurance policy that nobody can afford.
So the insurance company must ration the health care, and must therefore sometimes disagree with the attending physician as to the medical necessity of the proposed treatment. It does this on the basis of published medical evidence.
This criterion of rationing by medical evidence, like all criteria of rationing, evokes protests from people who do not receive the health care to which they feel entitled. For example, what shall we do about people who have rare diseases? Cancer of the adrenal gland, for example, is a rare malignancy. On theoretical grounds we might feel that it would respond to an expensive drug like Avastin, but no clinical trial has addressed that question. It is such a rare disease that there will never be a clinical trial large enough to prove or disprove the benefit of Avastin in treating it. Are patients who have rare and relatively unstudied diseases never to have access to expensive treatments of theoretical but untested benefit?
Another consideration is that medical evidence is not an all-or-none affair. No cure bursts forth onto the medical world fully formed like Athena from the brow of Zeus. First laboratory or animal models of a disease suggest a line of approach. Then small studies assess the treatments’ toxicity and efficacy in humans. Larger clinical trials are performed only if these early studies are promising. These trials are first reported at meetings before the data are mature. Subsequent reports may apprise clinicians of the progress of the study. Only when the data are mature are they reported in toto, and it is usually a while after that before the new treatment wins FDA approval.
When is the evidence sufficient? Shall we consider the availability of other treatments in making the decision, or weigh the evidence on its own merits alone? There is no one right answer. As a clinician, I may recommend a treatment early in its development, sometimes on little more than a hunch (with the patient’s informed consent), if the patient has few options and a dismal prognosis. Years later I’ll learn whether the choice was right or not. But the health plan also must decide: Shall we authorize this treatment and necessarily restrict another treatment? If so, which one? I remind the reader: Rationing is inevitable. Only the criteria of rationing may vary.
While the application of any standard of explicit rationing must be equitable, at heart the criteria themselves cannot escape some element of arbitrariness. Whether the criteria are age of the patient, life expectancy with or without treatment, cost of the treatment, rigor of evidence, or simply public clamor—rationing everywhere and always means that someone is denied health care which he believes is necessary for his wellbeing and to which he feels entitled.
Imperfect as it is, using the criterion of medical necessity based on medical evidence is likely the most just and practical way of performing the unavoidable and unpleasant task of rationing health care. Implicit rationing is dishonest and procrustean, bluntly mismatching resources and needs. Rationing by age or life expectancy inevitably leads to decision making based on invidious, not to say immoral, comparisons of individual worth. Rationing primarily by cost obviates the fundamental purpose of having health insurance. Rationing by public clamor introduces the injustice of preferential treatment for those with the greatest political clout. The optimist will consider healthcare rationing based on evidence-based medical necessity as the best of all possible ways of doing it; the pessimist will fear that he’s right.
As Congress and the people consider restructuring the American healthcare system, they must keep in mind that rationing health care may not be undeniable, but it is unavoidable. To claim that Congress will devise a new federal healthcare 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 healthcare 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.
You can bet your life on it.
Eric Chevlen, M.D., is a medical oncologist in Youngstown, Ohio.
Comments:
That's the question before us in health care reform.
And that's why there's so much anger. Because when the politicians deny that is the question, when they try to explain away that they are indeed proposing a rationing system, the people know they are (perhaps not intentionally) deceiving us.
The doctor and hospital both took urine samples (within the same hour). I asked why two samples needed to be taken and the nurse at the hospital said there was no reason the doctors office and hospital needed to run the test. So the nurse called the doc and received this response "the hospitals test is more encompassing so we wanted the hospital to also run the test". I said it looks like the doctor wanted another service "fee".
I said all this to say: Doctors rightly seek their greatest self business interest, more fees and "consultations". Insurance companies rightly seek their business interest, cutting cost.
Rationing is necessary. But please don't make the mistake of thinking the market can effectively ration healthcare. And don't count on the doctor reducing your cost either...
Thank you for this excellent, informative article. You make a strong, well-reasoned case, about a difficult topic -- right up until you get here...
"But the single-payer system to which Obama’s plan will lead..."
The notion that granting citizens the option to purchase insurance from a public plan will inevitably lead a single-payer system, with no competition, is not supported by arguments you put forth. You eloquently describe the different way public and private entities deal withe issue of rationing. Isn't it rational to assume, a premium-supported public health plan will deal with cost containment in a manner similar the existing public health plans? Won't private plans be able to compete with a public plan using their own, and alternate, strategies? Ultimately, won't the option to choose among plans be good for customers?
You also neglect to mention one, very common, way private insurers ration care. They start by deciding who they will insure in the first place. Deciding to deny a sick member treatment may be a difficult and rigorous process. Deciding that a potential costumer is a profit risk, and not worth insuring in the first place, is much easier.
I enjoyed your article. But you do yourself, and your readers, a great disservice by leaping to the unfounded conclusion that we must rely on for-profit, private insurers like your employer.
So, someone who is poor because they lay around the house all day and refuse to work should get the same quality health care of someone who works all the time to create a business and become wealthy? Sure, those are extremes, but nevertheless this is fundamentally what is being argued here. What's even more diabolical is that in essence it is stealing the well being from hard workers to pay for those that don't want to work at all since the more you take away from those who are productive, the more they have to work. An example would be if you tax someone more, they may have to work more and then no longer have time to go the gym, impacting their health.
But of course wealthy people don't actually work for it, right?
# government certification for med schools,
# gov't certification for the doctors or para-physicians coming out of the schools,
# reserve requirements for insurers that close the industry to new competition,
# regulations that hinder the formation of mutual benefit societies,
# requirements that doctors even be insured,
# gov't oversight of development of new drugs and therapies and new uses for existing drugs.
# lists of controlled therapeutic drugs (available only by prescription) or at least their limitation to only those drugs whose use has wider public implications (e.g. overused antibiotics, drugs with recreational uses),
# lists of services that by law must be provided by insurers,
and thousands of others. Along with tort reform (especially implementing a loser pay system and a clear judicial distinction between mere mistake and negligence) removal of just a fraction of the crushing weight of government regulation will render reasonably priced health care in a free market. Then private charity can easily cover those that will inevitably still fall through the cracks.
1. Insurers can't discriminate based on a preexisting condition
2. Eliminate practice of rescission
3. Requirement that insurers spend more money on medical care and less money on premiums
4. Out-of-pocket caps, so no one goes medically bankrupt
Ideally, as in many other countries (ex: Switzerland), the insurance companies would be non-profit for the base healthcare insurance, and could only turn a profit for supplemental insurance. Why is is you want winners and losers in a market for something like national wellness, exactly? Because is all markets there are losers.
This is not at all what is being argued here.
This is a simpleton's reasoning from "I Got Mine" libertarianism. There are countless stories of people who have worked their whole lives and paid into the health insurance "system" who have lost their entire life savings over medical bills. There is rescission. There is the ever-present pre-existing condition. There is the fact that people who lose their jobs eventually lose their health insurance (if they can afford the COBRA payments to begin with).
Not everyone who doesn't have health insurance is a lazy slob. Similarly, not everyone who is wealthy "works" for their keep. I have an idea: adopt a 100 percent inheritance tax so that each generation must start anew building its wealth, and then talk about your precious work ethic.
I certainly hope none of those fates ever befall you. But I am reminded of the parrable of the Good Samaritan. You might look it up sometime.
And, Dr. Chevlen, you buried the lead. This: "Before I became a consultant to the insurance company" is more important than its position two-thirds of the way into an overly long essay.
"pre existing conditions?" Those are forms of rationing too, are they not? Those are
not addressed in this article. I don't really care who provides the insurance, myself, so long as the insurance abides by a good set of rules (Andrew's 1, 2 and 4 make sense to me. Not sure what he's trying to do with #3, though. Gotta bring in premium in order to cover claims. Is #3 aimed at profits?).
Overall, I thought it was a good read. The main thrust (there must be rationing, of some type) is something I absolutely agree with. What I disagree with is the following:
1) That the "public option" will necessarily lead inexorably to single-payer.
2) That rationing under a single-payer system, should that be the end result, will be worse than the situation we have now. I agree, of course, that there will be rationing. I don't see why "medical necessity" would not be the standard under a government plan, just as it is with the good Doctor's private employer.
Also, oddly enough, I've mostly had good experiences at the DMV, and I think the Post Office does a rather good job. I can't comment on the INS. :)
Here's the bottom line: the thrust of the article, in the end, is that the private insurers are preferable to the government. I think it's one hell of an indictment of the private health insurance industry that I and many, many other Americans are not so sure about that. This is an industry that has "serviced" its customers poorly - so much so that they're seriously pondering going all socialist (!) and stuff. Think about that.
Once the government is taking care of everyone, that removes the individual's personal role in performing charity - and charity's supposed to be a big part of christian practice. Why do liberal christians (not to mention secularists who believe they're on the Lord's side on this issue) support the state doing all their helping for them?
1) HR3200 currently being discussed is projected by the CBO to have only 30 million in the Exchange by 2019 and only 10 million in a public option if we even get a public option. It will not lead to Single Payer! The original idea of Building Blocks as articulated by Jacob Hacker that would have lead to 129 million or so in the Public Option has been totally gutted by the monied special interests.
2) Although unjustly maligned there is a system of Evidence Based Medicine that works. N.I.C.E. in the UK makes a valiant effort to make rational decisions. It's not perfect, but it looks at things over again and again if necessary. In the UK they also have a private safety valve and 11.3% of Brits who feel they are being deprived of something they want can often get it.
3) Each of the Single Payer Bills before Congress; HR 676, HR 1200, and S 703 allow for the purchase of supplemental policies for non-covered benefits for those who can afford it and feel their wants and possibly their needs are not met.
Another excellent article, a prescient 1994 one, is "Health Care reform: A Free Market perspective" by Jeffrey
Fleur, MD and Eletheria Fleur, MD. Jeffrey Fleur, presently Dean of Harvard Nedical School, essentially argues from from Dr. Chevlen's position The article is at:
http://ecommons.med.harvard.edu/ec_res/nt/A29698DD-A40C-4FD2-9926-718E04778B37/HealthCareReform_Paper_Fall1994.pdf
1. There's no way that the U.S. will adopt a single-payer system. We MIGHT have a system like Medicare where the wealthy can (and do) opt for more care, while the majority of people make do with perfectly adequate care. I'm against a ceiling on medical expenses, but I'm in favor of a floor, and we don't have that now except for the old and the very poor.
2. I agree that rationing is inevitable. But right now, rationing decisions are made for us without our input. If we have employer-provided insurance, we don't choose our provider, and management may have different interests than employees (e.g., as a healthy graduate student I would rather have a HSA and a high deductible plan, but I can't ask for that). On the individual market, it's very difficult to find out what coverage is and is not available, and state-based market regulation is inefficient and ineffective.
3. The consequence of health care reform is that it puts all of us in the same boat. While conservatives like to believe that every man is an island, we know that's not the case. A strong and healthy civil society depends on individuals having roughly equal access to opportunity. When that doesn't happen, you get countries like Brazil, Egypt and Indonesia, which have a wide gap between the rich and poor and constant social unrest. While this may pay off for the rich in those countries, it violates the core of the American belief system.
If we're making decisions about rationing, I'd rather have those decisions be made as part of the political process, rather than by private monopolies. This is the real decision: do we let insurance companies ration, or do we as citizens decide what works for all of us.
An excellent article except for the last paragraph, which quickly made unfounded assertions and logical leaps to get to the conclusion. The conclusion of your argument seems to be that rationing is unavoidable, best left to being on the basis of medical necessity and medical evidence, and needs to be thoroughly considered in designing any healthcare system. The conclusion of your article, however, jumps to saying, essentially, "therefore the public option is bad." How are you certain that a public option would lead to a single payer system? How are you certain that a public option would use implicit rationing? How are your certain that a public option would be governed by cost and political considerations? I am not saying that you are necessarily wrong about your assertions, only that you provide no arguments to back these up.
The other point I would like to make is that after pointing out the inherent inequity in rationing based on personal wealth, you make the astute observation, that the alternatives "involve a large number of individuals agreeing (or having imposed on them) that the amount of health care they receive will not be in strict accord to how much they have paid for it." The basic problem with a market-based system like we have now is that this concept is inherently counter to the nature of a free market economy. With a large number of choices available to me for healthcare coverage that all ration different services, deny coverage to different individuals, and cost different amounts, why wouldn't I choose the healthcare coverage that provides only the services I expect to need and costs the least. This means people who are younger and healthier choose cheaper coverage (if they get coverage at all), because they don't expect to need expensive services, or they do not have conditions that would preclude them from these cheaper plans. This pulls those people out of the risk pool on other plans, making the cost go higher, which in turn encourages more people to forgo coverage, and this cycle eventually effectively puts us back at distribution by personal wealth again. This cycle has been slow, because many people were covered by plans from their employers, effectively pushing them into having the system "imposed on them", but the cycle is happening nonetheless and we are starting to see the effects of it, and employers will be less and less likely to want to take part in it.
This is a simpleton's reasoning from "I Got Mine" libertarianism. There are countless stories of people who have worked their whole lives and paid into the health insurance "system" who have lost their entire life savings over medical bills. There is rescission. There is the ever-present pre-existing condition. There is the fact that people who lose their jobs eventually lose their health insurance (if they can afford the COBRA payments to begin with).
Not everyone who doesn't have health insurance is a lazy slob. Similarly, not everyone who is wealthy "works" for their keep. "
I agree that those were extremes when I posted : "So, someone who is poor because they lay around the house all day and refuse to work should get the same quality health care of someone who works all the time to create a business and become wealthy? >>>Sure, those are extremes,
Fundamentally, the United States should be able to provide the best care in the world to all of its citizens for no more than it costs any other country (ie - more than Canada, which spends very little per capita.) To equivocate on this issue is to believe that American ingenuity and innovation is second-rate.
The development of pharmaceuticals is categorically included in such enterprise. In a capitalist system, the magnitude of profit is controlled by competition. Controlling it by other means has never worked well. So far, we don't have a better way of doing this. If you want to play around with the system, do it experimentally, in the microcosm, in the states, and only adopt nationally what actually works. The system is more complex than our brain trust in DC can handle. I don't care how smart they're supposed to be, they can't predict outcomes of this sort.
If we didn't have a capitalist system, we would never have encountered this problem. We would all be dying at a young age. We would be watching our children die of childhood disease. Think about it. Would you rather live somewhere where you can watch you kid die of some awful disease we routinely cure here?
"we didn't have a capitalist system, we would never have encountered this problem. We would all be dying at a young age. We would be watching our children die of childhood disease. Think about it. Would you rather live somewhere where you can watch you kid die of some awful disease?"
wGraves is so enmeshed in ignorance he is not aware that people live longer in socialist countries like Sweden and even live as long in Cuba as the US.
For more relevant perspective - http://bit.ly/2vKSdp
With all due respect, before you take the author to task, please give some consideration to the fact that there might be something you don't know about the US healthcare system, I use the term loosely.
Having worked in this area for 30 yrs, let me assure you that the last paragraph in this piece is not "hyperbole". As broken as this system is, there is absolutely NO possibility that the Feds Can Fix It. None.
How do I know that the 'public option' will negate competition? The same way I know that, as of this moment, there is viable healthcare option for a person who otherwise qualifies for Medicare. That public option effectively nixed all competitors &, lo & behold, the way that they're attempting to control those costs now is to attempt to introduce competition thru Medicare HMOs.
ALL of this is totally beside the point on a Catholic blog because, unless Abortion is explicility excluded, it WILL be included. President O stated specifically that "tax dollars' wouldn't be used for this but, lawyer-like, that doesn't state the truth that mandatory healthcare appropriations would be...which forces me to chose between the fed gov't and my religious beliefs...which means that I have to choose my religious beliefs which means that I'll be branded by the feds as a "rightwing mob person"...which means they'll do whatever is necessary to re-educate me...well, you get the picture.
For those of you who still think is all "hyperbole", perhaps you should go & purchase a good world history book.
All those working for the public option to determine whether a procedure is medically necessary will have the same case load as a social worker....Great...
The core argument seems to be that rationing is going to happen, but it's better that it be handled by a private insurer. That system seems to have provided us with the circumstances in which we currently find ourselves. That does not seem desirable, and besides, it leaves out the other less direct forms of rationing--the exclusion of people from the system for pre-existing conditions (among other things), the crushing burden of medical bankruptcy, and so on. There remains, of course, on top of this, the sad fact that we spend lots more per capita than other advanced nations for what can only be called less than proportionate outcomes, to put it mildly.
A couple more points. First, whether or not health care is a "right" is not an issue in the current debate, as some people seem to think. No one seems to be advancing that argument as the sole sufficient justification for revising the way we do health care. Besides, declaring rights are merely "negative" just begs the question against those who have a more expansive conception of right. Second, no one has proposed single payer, to suggest as much is to argue against a straw man. Besides, many other industrialized nations have found ways to do health care that are not single payer. So please put that aside.
It's nice to see an attempt to discuss "rationing"; but it would be nicer if it were minimally honest about well-established and comparatively successful alternatives.
As to rationing....that anyone in government suggests their plan will not cause rationing...well, we also had established in the 70's a new Federal Dept. of Energy and its role was to "reduce the reliance on foreign energy".
Coming back to Dr. Chevlen's article itself, I believe the points he wants make can and should be made in roughly 25% of the current length. I would also like to ask Dr. Chevlen how long he would be employed by the insurance company that currently hires him, if god forbid his " reasoning " had lead him to a position that is not to the benefit of his employer ? it's for this reason, that his insurance company affiliation should not be hidden way down in the article, as I for one and many others like me would like to know his bias up front!
There is no reason for profit in the healing services sector! Claiming, it is the profit motive that produces the great U.S system of medicine sounds good as a sound bite for investors. This assertion also ignores the fact that superb medical research is carried out in many countries besides the U.S!
as evidence that quite quickly talk of government health care turns to Marxism, considering abolishing inheritance is the #3 idea of Marx to communism...
hmmm... what an odd thing my post was clipped. I bet I just don't know how to use the internet, that's it....
Why on earth would anyone think government health care is socialist?
Dr. Chevlen is certainly right that health care decisions involving costs will inevitably have to be made by some people. He is also right that there is some advantage to private insurance over government coverage, since a private company cannot yet completely ignore its customers, while the government is so big that it largely can do so without fear of consequences. However, health care run by government and health care run by other large corporations is unlikely to be radically different given the same basic third party payer system. Indeed, this is one of the reason why the push for government health care as an improvement on the current system is so irrational.
You essay is well worded, thought out, wise, from one in the trenches, who has been outside of the trenches, unveiling the double talk, the unspoken words of those who make, propose, policy. In responding to the many comments above about other systems, the French, the Japanese, the Canadians, people fail to understand that our society is not like the others. We eat, sleep, run our business, engage, welcome, dispersant peoples, like no society in the world. The U.S. is different, despite globalization. People, patients, need "skin in the game," a financial stake, in the care that they receive, an American concept, a concept which promotes personal excellence, the ability to move ahead, with responsibility, taking risks, unlike any place in the world. Tocqueville understood this 150 years ago. It is part of what makes America, America. What is needed is uncoupling of health care from employment, portability, incentives for people to decide on their own what degree of personal monies they want to spend on their own care. Heath care savings accounts, the ability to negotiate personal insurance across state lines, the end to the absurd direct to consumer advertising from industry. And, honesty, the type of honesty that your essay espouses.
Is this a distinction without difference? I think not. Most obese patients would like to have liposuction; however, since they must pay out of pocket, they do without, and maybe go on a diet.
The consumer/taxpayer/patient tries to get as many medical goods and services as they feel they need without pay anything extra. What we need in healthcare is a system that pays 100% of what we need, but 0% of what we want, but don't need. For Medicare patients, I would advocate a system similar to what some states' Medicaid systems use -- all Medicare expenditures for a husband and wife are paid from their estate, payable after both have passed away. This of course would decrease the inheritance to their beneficiaries, but it would reinforce the fact that Medicare expenditures must be paid by some sort of tax.
The article continues: "It’s a funny line, of course, if somewhat harsh. I’ll probably let him out of his room in a few weeks. But his quip is largely untrue. Its bite comes from the fact that it’s not entirely untrue." (end of quote)
I had never heard the name "Eric Chevlen" until yesterday. Allow me to explain.
I am in the fight of my life. My wife was diagnosed with primary peritoneal cancer in June 2007. We are now battling it for the third time in three years. Although we live on the West Coast, we have gone to the MD Anderson Cancer Center in Houston - at great effort and cost - to get some of the nation's finest cancer treatment.
The highly qualified team at MD Anderson Cancer Center, upon careful study of my wife's condition, recommended a particular treatment. But an "Eric Chevlen" - according to the document I received yesterday - has preempted my wife's MD Anderson Cancer Center treatment, thus saving Anthem Blue Cross significant sums of money.
Mr. Chevlen's son got it right when he said, " “Gee, Dad, ... your new job is denying it.”
However, Dr. Chevlen got it wrong when he said, "It’s a funny line..." It is not funny. Not at all. Now, in addition to being a primary caregiver for a sick wife, I have to take on a healthcare goliath.
Chevlen was much more accurate when he said, that the comment was "somewhat harsh." But sir, it was not your son's comment that is harsh. Dr. Chevlen, it is your rulings that are harsh, or at least have harsh impact...on people...on spouses...on children. You, by your ruling, may be taking away my wife's life, taking her away from her four adopted children, and her five grandsons.
You write, tongue in cheek, regarding your son, "I’ll probably let him out of his room in a few weeks." Sir, I am not sure it is your son that should stay in his room.
You say that "his quip is largely untrue." Well, not in our case. Then you write, "Its bite comes from the fact that it’s not entirely untrue." Bingo!
It is NOT entirely untrue. After careful consultation with an entire team of top flight specialists at MD Anderson Cancer Center in Houston, along with our crack team here in California, you (sitting in an office in Ohio - far removed from the precise conditions surrounding my wife's case) have made a ruling that - while saving your company thousands of dollars - may take from me my wife of 39 1/2 years. Want to read her story, Doctor? Go to www.skylinechurch.org & click on Carol's picture. And I appeal to you to change your mind - before it is too late.
I wish you would cut this article in half and submit it to a publication like USA Today or Newsweek. I have not seen such a succinct and crucial vocabulary adjustment as you are offering in this most welcome national debate.
On Medicine as a GOOD
The distinction between good and right is very important and Catholics have been among the worst offenders furthering this confusion. This important distinction has not yet been incorporated in the debate.
ON RATIONING
Any time there is a limited amount of goods, it is better to have a rational(based on some "ratio"-reason) form of distribution,. Sometimes(very often) the most rational form of distribution is the pricing mechanism in a free market. This is often true in the world of medicine also but with many essential caveats as you point out.
The SOURCE of MEDICINE as a SOCIAL GOOD
One very important element I think you might correct though is your statement "Until modern times, health care in the United States was distributed as most goods of life are distributed—according to personal wealth." There is some truth in that statement but not enough to clarify. Actually the good of medicine was distributed largely from the works of charity coming from religious duty to love one's neighbor(Check out the original names of twenty hospitals in your state before they were merged or read a short history of Mayo Clinic ). Added to this was a much more robust sense of the medical profession's ethics of duty to care for the sick(the teaching hospital was one way we fulfilled this duty as doctors and educators). The withering of social capital on the provider side is as big a part of the problem as the turning of the needs of the sick into the unquenchable demand of "the consumer" for wellness. There is a lot more that can be written about this and it would fit nicely as a third leg in your explanatory vocabulary of rationing and goods. I hope you see this as a refinement of your excellent observations. I am a radiation oncologist and I am happily accustomed to cleaning up and clarifying with more targeted therapy after the systemic shotgun of chemotherapy has been delivered by medical oncologists.