Healthcare Rationing Needs Thought Now

I am sitting near the fireplace in the comfortable lounge of a gleaming new  medical treatment center that I am told cost $150 million, ready to begin treatments for a  problem many mature (old) men face. I have read that my treatments will cost about  $100,000, though I will probably never know because the bills go to Medicare and my  secondary insurance carrier. 

Thinking to myself, I ask: Can we afford all this? The answer, obvious to me  anyway, is no, though I hope this is not discovered until after my treatments. In the U.S. we spend more than $2.6 trillion (remember when a billion was big) a  year on health care, or more than $8,000 per person. According to the New York Times,  this is more than all the 65 million people in France spend on everything, that is, more  than that country’s gross domestic product.  

Health expert Ezekiel Emanuel (brother of Chicago mayor Rahm Emanuel) notes  that American health care expenditures alone would represent the fifth largest economy  in the world. By 2035, if present growth rates of about 7 percent a year continue, we will  be devoting fully one-third of the American economy to health care. 

We might think of these expenditures as not for patient care but instead as the  feeding of a huge industry. We patients are conduits for the money. As long as hospital  additions and specialty centers continue to blossom and pharmaceutical companies come  out with personalized genetic therapies, we will continue to feed the beast. A benign, wondrous beast, yet one that will soon sap the strength of our economy and crowd out  spending for education, research and investment, as some would say health care is  already doing. 

There are ways we can cut health care expenditures without affecting the quality  and availability of medical care, for awhile. We can cut administrative costs by creating  virtual patients, whose on-line medical information is known to all health care providers,  but it will be costly and controversial. We can put low-income Medicaid patients in  managed care (the old HMOs), which the larger public rebelled against a few years ago  because it appeared to limit, that is, ration, care.  

We can bundle care so that the poor and uninsured receive full wrap-around care,  which ironically would, Ezekiel Emanuel believes, cut costs by keeping patients out of  emergency rooms.  

Yet no matter how much more efficient we might make health care, the costs will  ultimately outstrip these savings, as technology and life-extending therapies become  more exotic. 

Many developed countries already ration care. Moline native and Yeshiva  University law professor Edward Zelinsky offers a graphic illustration. Zelinsky recently  lost two friends to terminal cancer, one in America, the other in Israel. 

The American received the full panoply of advanced anti-cancer treatments over  two years, after which he died, as doctors had predicted would be the case. The Israeli was much younger than the American and father of a child, yet the  Israeli national health insurance system and Israeli doctors made no effort to prolong his  life.

The Israeli system did a better job of controlling costs than did the American  medical system. But it did so by denying care. 

We don’t want that, and elected officials will for the moment decry such ideas,  but someday we will have to consider it.  

So we should begin now to think about the issue and of how to most humanely  ration care. All of the options are awful. We could ration care on the basis of the number  of the “quality-adjusted life years” that an expensive medical procedure would bestow (which was probably what the Israeli system did in our example). 

We could ration on the basis of age or of behaviors such as smoking, heavy  drinking and gross obesity, wherein patients might receive less acute care than others. We  could prioritize all health therapies by outcomes, and cover only those down to a place on  the list that we could afford.  

I don’t really know, and neither do you, I suspect, which is why we need to begin discussing the matter now. It will take years to come to anything close to consensus, and  the discussions will be understandably emotional. 

I propose that several states each create blue ribbon commissions of doctors,  ethicists, and thoughtful common folks to begin discussing “The Future of Health Care in  America.” That way, we would have several panels at work, rather than just one national  group. 

I predict that the next generation will be forced to ration more than we already do  today (for example, I doubt the uninsured today would be offered the treatments I am  going through, which is certainly rationing). We simply cannot afford all the marvelous  health care that can be made available.