The price of covering everyone

Maggie Mahar takes on rationing and admits that it has to happen:

Now that we seem to be reaching agreement that we no longer want to ration care according to ability to pay, we will have to begin discussing how to ration care some other way.

She further questions the focus on the latest and the greatest therapies to cheat death:

It strikes me that before we pour vast sums into customized medical care based on genome research, we might ask whether we, as a society, will be able to afford such care. Or will this be medicine only for the wealthiest few?

As a society, Americans are conditioned to “beat death.” With that mindset, it will be difficult for many to accept bare-bones coverage, a la Medicaid.

Unfortunately, the cost of covering everybody is going to be prohibitive. Those used to gold-plated health plans are likely to be disappointed with the proposed offerings that will come out with any major reform plan.

topics: universal coverage, rationing

Comments

The Happy Hospitalist
Just the other day I had a conversation with a POA, a bone-e-fied respiratory therapist. I had to explain to her why it was NOT appropriate to put her 82 year old severely demented father on a respiratory and perform chest compressions in the hospital, should he go south while in the hospital.
These are medical personal who live the lie of maximum support every single day and still can’t find it in themselves to do the compassionate thing for their family members. Some people just don’t get it. No matter who they are or where they come from.
I asked that they at least think about it. What else can I do?
Chuck Brooks
Another opportunity for concierge medicine further down the funnel, for those who don’t have to ask how much it costs. For everyone else, there’ll be a black market response to rationing, however well intentioned it may be at the beginning. Not everyone will be reasonable in their expectations, and the politicos will be there to exploit the possibilities.
Chuck Brooks
FutureWare SCG
MM
Every discussion on rationing, at some point, makes the appeal that the rationing has to be “intelligent”. Intelligent by whose standard? Mine? Maggie’s? DrRich’s? Joe the Plumber’s? Yours? (I vote for spontaneous order, but a single payer system is certainly not that) This is such a subjective term, especially when taking into consideration the person who is using it at the time.
Whatever healthcare rationing occurs, you know the rationing standards will be set by someone in government, be it legislator or regulator. I want to know, given the influences and money involved, who ever gets the idea that such “intelligence” is going to come out of government? No rationing policy will be “intelligent” because it will always be set by a small group of people who are incapable of collecting all of the possible information on the myriad sets of possible circumstances that occur on a daily basis.
The soviets couldn’t even get bread where it was wanted and needed, so what’s the chance of the US getting healthcare where its wanted?
David Harlow
Umm, we already ration care, folks. The trick will be how to do it explicitly, according to some clearly articulated (and, one would hope, agreed-upon and rational) principles. The cost is already prohibitive, and it’s getting worse, not better. As more folks obtain health insurance they add even more cost to the system (particularly if they were uninsured and therefore delayed care for a while). Evidence-based medicine has a big role to play, as do other means of keeping the waste in the current system in check. It’s not an entirely futile exercise, as the previous commenter suggests, since any explicit system with a modicum of rationality will be better than the current unacknowledged rationing system. Some folks will always opt out of whatever system is constructed (just as they do in the variously glorified or vilified national health care systems out there in the rest of the industrialized world). That’s not a reason not to build a better system.
David
MM has it right. Spontaneous order, which arises out of a capitalist system, is the best “system of rationing” if you will. In non-emergent cases, each person decides for themselves what they are willing to pay for, how much trouble they will go through, what they can afford for their own health care. In emergencies, then of course health insurance (if you have it) has to be involved. If you don’t have insurance, then you must depend on the charity of others if you need health care.
Those who think that there are too many uninsured should be working to improve the system (see below) or should be reaching into their own pockets (not mine) to help out the uninsured.
But the current health care system is in a highly eroded state – not because of capitalism – but because of its opposite. By proclaiming that health care is a right, or that providing health care to others is a ‘moral obligation’ we have muddied up the thinking. Muddy thinking of this sort leads to muddy laws, interference in businesses, endless controls. It would take hours to try to enumerate the many ways in which government involvement, bad laws, and an out of control tort system have adversely affected health care in this country. This process, over years, is destroying the industry.
When people complain that there is waste in the system, that health insurance is too expensive, that the insurance industry is cold to their needs, etc. – they perhaps don’t realize that it is largely because of government controls, interference and participation in the industry, and bad laws that are leading to these problems.
And, instead of thinking deeply about the problem, which is a complex one, they perhaps don’t realize that in throwing their hands up and arguing for a ‘single-payor’ (that is socialized) system – they are advocating the use of the very poison that has caused the disasters to date.
Anonymous
Maggie is wrong–there is most definetely not agreement against rationing by ability to pay. I am for it, not as flawless, but as less flawed than the alternatives–all of which put the most intimate, personal, and value laden choices in our lives in someone elses hands. Let’s face it, not everyone who is uninsured because they can’t afford it. Many have already made the decision that health insurance isn’t important to them, and in doing so have already rationed their own care limiting it to what they can afford out of pocket or guilt the rest of us into giving them.
And not everyone who can’t afford insurance is a helpless victim of fate such as poor genes which leave them unable to give their labor much value. Many have simply made choices to value other things over working or raising the value of their labor–maybe hanging out at the beach–and in doing so have also decided that healthcare is not a very high priority to them. Why should their healthcare be a high priority to me then?
Many of us think economic rationing is, with a few exceptions, just fine as it reflects individual differences in the value put on healthcare just as do other economic decisions. It is the rationing that most respects individual autonomy and dignity.

The price of covering everyone

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