I have begun to argue that controlling health care costs will require that we make a greater distinction between medical “treatments” and “services.” Treatments involve diagnosing and treating actual disease (roughly stated), while services involve using medical means to fulfill lifestyle or personal desires (roughly stated). I believe that coverge should mostly be restricted to treatments, and that to better control costs, most services should not be paid for at all (understanding that there are some gray zones).
A story out of the UK helps illustrate my thinking. The NHS—already going broke—is expanding coverage for IUI insemination to lesbian couples and raising the age for free access to IVF to age 42. From the Telegraph story:
Same-sex couples will be given the same rights as heterosexual couples under guidance issued by the National Institute for Health and Clinical Excellence. The NHS will also extend the upper age limit for IVF by three years to 42, following advice that suggests many women in their late 30s and early 40s could conceive after treatment. The move will see thousands of women a year given the chance to become mothers without having to pay up to £8,000 to private clinics. Fertility experts also questioned whether health authorities could afford to widen eligibility criteria, when only a quarter currently fund three cycles of IVF for infertile couples, as recommended by Nice...
The new guidelines call on health authorities in England and Wales to fund fertility treatment known as intra-uterine insemination (IUI), using donor sperm, for people in same-sex relationships. If they fail to conceive after six cycles of IUI, they should be considered for in-vitro fertilisation (IVF), which is much more costly and involved. The move follows a relaxation in the law, made under Labour in 2008, to put same-sex parenting on an equal legal footing.
This is an example of why we will never control health care costs if we keep expanding coverage for services in an evaporating payment pool. Frankly, it’s nuts.
In the lesbian example, there appears to be no indication that the women have to be unable to conceive through sexual relations, just that they are gay. I get it. But should society pay for the cost when it isn’t really a matter of disease or an inability to get pregnant?
Ditto a woman being unable to conceive as she gets older. That’s not illness, that’s nature. In such cases, shouldn’t the cost of IVF be on the woman and not the health payer? (By the way, I think the same thing about Viagra unless impotence has a medical cause, such as prostate cancer. It is not a treatment to enable older men to rev their engines like the could when they were 18.)
Meanwhile, remember that NICE rations bonafide medical treatments needed to sustain life and diagnose disease based on quality of life. We can expect the same kind of topsy/turvy thing here if Obamacare sticks: Governments making coverage decisions as much on politics as the necessities of health.
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