In health care, rationing is not a new concept

Rationing is defined as the controlled distribution of scarce resources, goods, or services. In health care, rationing is not a new concept and has been occurring for years, most often in times of emergency but also when resources are merely limited or demand is greater. For example, an increased need for ventilators in the winter months during flu epidemics; organ transplants are dictated by the availability, or the shortage, of hearts, kidneys, lungs and livers; limited numbers of “iron lungs” in the 1940′s for polio patients.

The topic of health care rationing has frequently been a subject of discussion but has taken center stage recently and is on the mind of most every citizen. Health care was one of the major platform issues for every candidate in the 2008 presidential election. As the election heated up, IT became one of the pivotal issues along with the war in Iraq.

Philosopher Peter Singer, the Ira W. DeCamp Professor of Bioethics at Princeton University, Laureate Professor at the Centre for Applied Philosophy and Public Ethics at the University of Melbourne stated the following in an article printed in the New York Times:

If the Department of Transportation [followed the principle that it was impossible to put a dollar value on human life] it would exhaust its entire budget on road safety. Fortunately the department sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million. Other government agencies do the same. Last year the Consumer Product Safety Commission considered a proposal to make mattresses less likely to catch fire. Information from the industry suggested that the new standard would cost $343 million to implement, but the Consumer Product Safety Commission calculated that it would save 270 lives a year — and since it valued a human life at around $5 million, that made the new standard a good value. If we are going to have consumer-safety regulation at all, we need some idea of how much safety is worth buying. Like health care bureaucrats, consumer-safety bureaucrats sometimes decide that saving a human life is not worth the expense. Twenty years ago, the National Research Council, an arm of the National Academy of Sciences, examined a proposal for installing seat belts in all school buses. It estimated that doing so would save, on average, one life per year, at a cost of $40 million. After that, support for the proposal faded away. So why is it that those who accept that we put a price on life when it comes to consumer safety refuse to accept it when it comes to health care?

An interesting question since all of us responsible for the family budget do much the same thing on a daily basis. Many times my own children will say “I want …”. and my answer is “There is a big difference between wants and needs.” and that is true for every aspect of life so why not health care?

The idea of rationing health care came from the National Institute for Health and Clinical Excellence (NICE) making a recommendation to the National Health Service that it should not pay for Sutent, a drug to be used for advanced kidney cancer. At a cost of $54,000 it would potentially extend a terminal advanced kidney cancer patient’s life by six months. NICE calculated the cost of a life per year at $49,000, meaning that Sutent was more expensive than a life was worth to save. A huge uproar in England made NICE reverse their original decision, but mostly because it would be used so infrequently as to be a non-issue. This fracas was then used as political ammunition against Obama and the Democrats that the Affordable Care Act amounted to rationing of health care. Duh!

Of course it will. Whether the insurance coverage you receive is from your employer or the government, it will only cover what they can afford to pay. Even the best “Cadillac” health care plan offered by commercial insurance DOES NOT cover every potential illness, condition, prescription or treatment. Will Wilkinson said it like this:

Individuals trade reductions in risk of death against other goods in the context of their own limited budgets. (I.e., they ration their resources.) What you are willing to pay to reduce the risk of death depends in large part on how much you’ve got to spend. If individuals with a ton of money spend boatloads on medical care, they are thereby revealing how much they are willing to pay to reduce the risk of death and are thereby pushing up the average willingness to pay for extra life. For the government to step in and limit spending on medical treatments on the basis of the fact that the limit reflects the average willingness to pay for extra life is exactly like government stepping in to limit how much individuals can pay for extra safety features on a car on the basis of what people do tend to pay. This stupidly takes an evolving average as normative while cutting off the possibility of further evolution.

Of course the government, like individuals and families, has a limited budget. So if the government is going to pay for medical care, it has to ration. And that very fact is an argument for limiting the government to only paying for the care of people who are unable to pay for a minimum of care themselves.

This makes sense from the standpoint that those who exploit our current “free” system of universal health care, are the ones that need government sponsored health care. The rest do not and can afford to pay what they feel is an appropriate amount for the level of coverage they receive. It will result in a two-tiered system of health care, but we and every other country in the world have one already.

Even Islamic Pakistan places a value on life. The recent arrest of a US CIA contractor for killing two Pakistani men resulted in his acquittal after “blood money of more than 2 million was paid to 19 family members of the “victims” (the contractor claimed self-defense and the US tried to state he was covered by diplomatic immunity). That gives us $105,263.63, the value each family member placed on the life of each victim killed, at least in Pakistan.

And consider the following tongue in cheek assessment of “value.” A man asks a woman if she would have sex with him for a million dollars? She reflects for a few moments and then answers that she would. “So,” he says, “would you have sex with me for $50?” Indignantly, she exclaims, “What kind of a woman do you think I am?” He replies: “We’ve already established that. Now we’re just haggling about the price.” And so, we have established that this “value” is negotiable.

The bottom line of the discussion of “rationing” comes down to what is the value of a human life and who will be the one to determine that value. Of course each of us would consider our own selves more valuable than another. Do we take into consideration the value of education, contributions to society, intellect, accomplishments, current chronic illnesses, taxes paid, number of children, pedigree, occupation or merely accept that the value of a life … mine, yours or the President of the United States, is merely an average of all factors combined. Would you be satisfied with that value in exchange for health care for everyone?

“Doc B” is a physician who blogs at One Doc’s Opinion.

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