Rationing Health Care

In the Sunday, July 19, 2009, New York Times, an article authored by Peter Singer entitled “Why We Must Ration Health Care” made the argument that public, and probably private, health insurance should limit payments for medical treatments that are not cost-effective in delivering health improvement. He makes the argument that “Health care is a scarce resource, and all scarce resources are rationed in one way or another.”

While there are many compelling points in Singer’s article, I feel that he has analyzed the problem of health care costs at the wrong place with the wrong argument. The problem of runaway health care costs starts with the root cause of having too many people that get sick or injured by failing to take proper care of themselves. The vast majority of our costs are a result of front-end behaviors by individuals who deteriorate over time and incur significant costs from preventable chronic diseases.

We should treat their unhealthy behaviors as choices to be big health care system users at some later time, and penalize those behaviors to discourage them. For example, a person who smokes heavily throughout his or her life is very likely to be a heavy user of medical services later in life. A person who allows himself or herself to become obese will be diagnosed with either Type 2 diabetes, hypertension, cardiovascular disease, or muscular-skeletal problems. In each of these cases, unless we make these individuals pay for the higher-risk behaviors in which they are engaging, they will be underpaying for the subsequent demands they place on our health care system. To me, we will get far more effective results asking people to pay more earlier in their lives for health care than we will be denying them care when they need it at a later time.

Relative to quality-adjusted-years-of-life metrics which determine the cost-effectiveness of medical treatments, I would make two comments:

• These metrics are averages over an entire population, which means that the treatments are highly effective for some people and totally ineffective for others. Rather than simply pricing them out of everyone’s range, we should focus more on research that enables us to determine why they work for some and not others. Over time, we can have a range of outcomes against which we can judge whether we will pay for the care, rather than treating diverse people the same. In some cases, it may be a good decision to pay, and, in others, it may not. This is true even for highly cost-effective treatments: there may be some individuals for whom the treatment is not likely to work, and we should not pay for it.
• When the treatment is designed to address a life-threatening, terminal medical condition like cancer, the person with the medical condition is often willing to get the treatment solely to buy time until something better comes along. If we are to get the public comfortable with denying payment for treatments that only marginally extend life, we also have to calculate whether there is a reasonable likelihood that a better treatment will emerge during the extended life period. That element should enter into the quality-adjusted-years-of-life calculation, so that the individual knows that the odds of surviving long enough to get a better treatment are also very low.

End-of-life care is a major financial drain on our health care system, and it also does not produce good outcomes for the individual because the quality of those last few weeks and months of life is often extremely poor. Recently, I attended a briefing by Dr. Neil Wenger of UCLA Medical Center who made a compelling argument that one of the weaknesses of end-of-life care decisions is that those making the decisions do not take into account the excruciating pain, the shortness of breath, and the other physical discomforts the individual experiences when he or she is having life extended. There is no mechanism for an individual to register these sensations and to express a point of view about how aggressively he or she wants life extended, especially if the odds of getting better are very low.

Current living will documents do not adequately address this all-too-common problem. They are very good at addressing cases in which individuals are in an irreversible coma, or have no continuing cognitive functions. They do not deal at all with excruciating pain and discomfort which totally interferes with an individual’s ability to experience even the smallest and simplest life pleasures.