July 25, 2009

Medical muddle

The NYTs asks its readers in relation to medical care:

"We’d like to know what you think about the prospect of rationing.

As if medical care for every man, woman and child, insured or not, isn't already rationed in irrational and extreme ways in the US - and rationed everywhere else, somewhat less irrationally.

The invitation to comment section follows on from an article by Peter Singer who, being one of our best known exports and rightly fawned over for his crisp, unsparing, logical thinking, really should know better than to assert, right at the outset, that health care is a "scare resource", hence the need to
consider rationing in the US.

Fact one
: health care is not scarce, or at least it need not be. Train more doctors, surgeons, specialists, nurses and ancillary specialists, build more medical centres and hospitals. Scarcity problem fixed. For a moment. If the doctors' *union* permitted it to be so.

Bread isn't scare and it's dirt cheap, ditto milk, and plastic bracelets from China. But here's the thing: bread and milk do not have unlimited demand. There comes a point where we have "enough" bread and "enough" milk, and "enough" plastic bracelets. We might still be hungry and we might still want more adornment around our person, but instead of buying another loaf of bread we buy a dozen lamb chops, at greater expense, or a slab of beer instead of milk, at even greater expense still, or a tiara to decorate on our heads.

Scarcity in and of itself, as I've noted many times before, isn't the central issue when discussing the provision, distribution and cost of medical care. Unlike other goods and services, including scarce and even finite resources, demand for health care is perceived to be unlimited, and perhaps real demand truly is unlimited, but since health care is rationed, the limitations of demand have never been tested in any country.

Humans only want so many loaves of bread, but when it comes to health care they're insatiable, and, we could suggest, irrational in their demands and expectations. Consume until it hurts seems to be the going currency for health care.

Fact two: ipso facto, medical resources always have and always will be rationed, mostly on the supply side, partly on the demand side - the latter being because people do make a choice over their level and frequency of medical care consumption, even when it's ostensibly free or extremely cheap.

three, which Singer never gets a handle on, even though his entire piece is set around the value, and therefore the price, of a life: 80% of health care expenditure is chewed up on the last six months of people's lives. Keep in mind that this encompasses anyone's last six months and doesn't signify that all those "old folk" are being kept chugging along unnecessarily. The nearer to death, the higher the price of saving a life, no matter a person's age or health problem and the more desperate and irrational the demand for heroic medical intervention.

Fact four: if the US ever finds the gumption and humanity to provide universal (and therefore, genuine community risk rating) health care, demand will go up, since people currently unable or averse to seeking medical care when it's needed will have a somewhat more forgiving choice than they have a the moment. This doesn't and shouldn't mean that their current humongous expenditure on health care will increase. Universal cover could be provided at lower cost than the one sixth (and growing) of US GDP being chewed-up for poorer health outcomes compared to other developed countries.

Bizarrely, again taking account of Singer's rightly vaunted reputation, he discusses the options for the US, offering this bright little nugget:
"Rationing public health care limits free choice if private health insurance is prohibited. But many countries combine free national health insurance with optional private insurance. Australia, where I’ve spent most of my life and raised a family, is one."

Hands up everyone with private health insurance who feels they have unlimited and unrationed health care choices?

Oh, that's right: we don't! No one does. Anywhere.

We can only procure approved medical interventions, which in itself is a sledge hammer mechanism for rationing, and not a bad one either, since the standard is set high so as to minimize harm and maximize good to the greatest number of people.

We also pay an arm and a leg in out of pocket costs for having, for example, a routine surgery next week instead of next year. Yes, that's certainly a choice, but just as many who have private cover will choose to have a surgery done under Medicare next year, rather than carry any of the extra cost of choice and have the surgery next week. Risk management and cost / benefit assessments in exercising choice still, largely, sit with the patient.

However, Singer's point is valid, to the extent that little Aussies aren't kept awake at night disturbed about the coexistence of public and public medical insurance. It's not difficult in theory nor in practice.

Importantly, unlike in the US, health insurance companies in Australia have no role in decision making over treatments, surgeries, drugs, or medical tests. Nor should they, ever. They're insurers, with no medical qualifications - they should stick to actuary calculations and butt out of anything to do with medicine or science. No doctor in Australia has to check with a private insurance company before ordering a test, or prescribing a drug, or ordering a surgery. Their time isn't wasted in having to consult and get the nod from an unqualified person. All of those activities simply go ahead, with the only concern for the patient being who pays what and how much. For the most part, our out of pockets, not to mention our insurance premiums, are tiny compared to those faced by our friends in the US.

In the US, private health insurance, mostly tied to employment, is subsidized to the tune of around $200B a year in tax deductions to employers (a historic practice introduced during WWII). Hardly what you'd call a "private" cost. (Singer acknowledges this aspect of the system as being one that needs to be abolished, that is, tying medical insurance to employment.)

Oddly, Singer doesn't advocate freedom of decision making for doctors, in consultation with their patients, he sees this as a legitimate component of rationing in a reformed US health system:
"... extending Medicare to the entire population, irrespective of age, but without Medicare’s current policy that allows doctors wide latitude in prescribing treatments for eligible patients. [emphasis added]

Every American will have a right to a good standard of health care, but no one will have a right to unrationed health care. Those who opt for unrationed health care will know exactly how much it costs them."

Again, no! There is no such thing as unrationed health care, anywhere, unless he's talking about those who resort to unscientific and unfounded treatments and interventions - the snake oil options not covered by any kind of insurance. Also, anyone charting their own course on pick a box medicine, with an unlimited budget, is very likely to have little clue of how much that path will cost them until they get to the end, and even less clue as to the likely success. We can't buy life or well being folks, at least not yet.

In any case, the Singer article is longish and doesn't present any arguments that haven't already been done to death (was his agent provocateur hat at the drycleaners?), but still of interest as it provides some level of insight into the singular confusion that the US has spun around this singularly crucial social good.

Why we must ration health care

The comments are a nutty mix of those who are quite convinced that they actually have full - unrationed - choice in their health care, as determined between only them and their doctor, and those who are quick to identify the overarching shortcomings in Singer's piece.

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