NYT: Why We Must Ration Health Care

[FourScore]

I posted this and then deleted it. But it set off such a great debate that I have decided to repost it. Sorry for any confusion. I'd love to know what people have to say about this!

Why We Must Ration Health Care
By PETER SINGER
Published: July 15, 2009

You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?

If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.

In the current U.S. debate over health care reform, “rationing” has become a dirty word. Meeting last month with five governors, President Obama urged them to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintons’ attempt to achieve reform. In a Wall Street Journal op-ed published at the end of last year with the headline “Obama Will Ration Your Health Care,” Sally Pipes, C.E.O. of the conservative Pacific Research Institute, described how in Britain the national health service does not pay for drugs that are regarded as not offering good value for money, and added, “Americans will not put up with such limits, nor will our elected representatives.” And the Democratic chair of the Senate Finance Committee, Senator Max Baucus, told CNSNews in April, “There is no rationing of health care at all” in the proposed reform.

Remember the joke about the man who 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.” The man’s response implies that if a woman will sell herself at any price, she is a prostitute. The way we regard rationing in health care seems to rest on a similar assumption, that it’s immoral to apply monetary considerations to saving lives — but is that stance tenable?

Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. But our current system of employer-financed health insurance exists only because the federal government encouraged it by making the premiums tax deductible. That is, in effect, a more than $200 billion government subsidy for health care. In the public sector, primarily Medicare, Medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals.

The case for explicit health care rationing in the United States starts with the difficulty of thinking of any other way in which we can continue to provide adequate health care to people on Medicaid and Medicare, let alone extend coverage to those who do not now have it. Health-insurance premiums have more than doubled in a decade, rising four times faster than wages. In May, Medicare’s trustees warned that the program’s biggest fund is heading for insolvency in just eight years. Health care now absorbs about one dollar in every six the nation spends, a figure that far exceeds the share spent by any other nation. According to the Congressional Budget Office, it is on track to double by 2035.

President Obama has said plainly that America’s health care system is broken. It is, he has said, by far the most significant driver of America’s long-term debt and deficits. It is hard to see how the nation as a whole can remain competitive if in 26 years we are spending nearly a third of what we earn on health care, while other industrialized nations are spending far less but achieving health outcomes as good as, or better than, ours.

Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?

http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?em

[Skittles]

1. how about asking why that drug costs $54,000

how about asking that?

[obliviously]

3. Far to easy! N/T

[scarletwoman]

6. Yeah, really! How about asking that?

I had the same reaction -- why the fuck does a drug cost $54,000? What's it made out of, powdered unicorn horns?

[mwooldri]

12. This is what happens in the UK's NHS.

They do say X drug costs too much, we're not buying it.

Plus in England and Wales, the NHS is an "all or nothing" system, either all treatment is covered, or you totally go private - you can't "top up" the NHS. You generally can't be seen by your regular NHS doctor, and pay for that private prescription out of your own pocket the NHS doctor gives you. If this is the case, the doctor would be working privately and would have to charge you for that visit too. The Scottish NHS does allow a mix of private and public funds for treatment (e.g. patient pays for non-covered NHS drugs, but NHS pays for doctors, nurses, hospitals, etc).

It is a game of cat and mouse... big pharma wants paid, but NHS doesn't want to pay. Big pharma then decides is lowering the cost and bargaining with the NHS profitable, or whether they should just not supply the UK with the drug. Also clearing a drug for sale is different to making it available on the NHS. This is certainly the case with some cancer drugs right now... some European health care systems will cover the more expensive drugs, but the UK won't, and the pharma companies say "well France is buying the drug at this price, and you're denying your citizens the treatment that helps them".

I certainly believe in the USA a centralized drug purchasing process would definitely drive down the costs of the more expensive drugs because the USA is a much bigger market. It could in theory be possible with adding a responsibility to the FDA for allowing drugs to be sold... certifying for affordability too. The danger is that the drugs that might be developed by big pharma may never get to market, or it greatly slows down the process of medicines coming out (hanging onto patents), but this can also be overcome by providing more grants for universities to research medicine and drugs and let them develop the drugs. Universities do this at present, but more money couldn't hurt the process.

[Progressive_In_NC]

23. I work for several pharmas, and if they do hold the cost of drugs in the USA

New medicines will cease to exist in just a few years.

The drug costs $54,000 because it took several BILLION dollars to get that drug to market. Then you have a finite group of users and you have to pay back the loans you took to go through multi-round FDA MANDATED (and rightfully so) clinical trials. Then you have to go to market with the drug and pay for the distribution of said drug. Then you have to figure in the costs of the Patient Assistance Programs (which I help run) for the poor among us.

Then you have to take into account that other coutries won't let you charge a balanced amount of money to recoup your investment so you have one market left to try to turn a profit on creating this drug....the US. The sad fact is, even if you took profit out of the cost of bringing the drug to the people, it would still cost around 45,000.00 a shot.

[NashVegas]

26. Which New Medicines Would Those Be?

Like the ones correcting marketing-driven diseases like "female sexual dysfunction?"

[Nickster]

28. And how much of that R&D was paid for out of taxpayer funds?

[sendero]

33. There are some drugs....

. that should just never be developed. They were developed based on the business model of insurance paying an infinite price for a dose.

The incentives in the system are all wrong and must be corrected.

[Liberal In Texas]

39. Isn't over half of that "R&D" spent on promotion? I see the drug reps bringing all kinds of gifts

to my docs office. They cater lunches, they give them wall charts and pens and pads and scads of free samples (like a street corner drug dealer, the first taste is free) packaged in elaborate boxes with lots of bubble packaging for each pill.

And some of the R in the R&D is done to change one molecule in a drug so the patent can be renewed and the drug is rolled out under a new name. Most of the R is also paid for by taxpayers because the research is done at universities and places like the NIH.

Here's a snippet I just found:

"Drug makers spend nearly $60 billion a year marketing their products, twice what they spend on research and development, according to a study published in PLoS, a journal of the Public Library of Science."

http://www.forums.pharma-mkting.com/showthread.php?t=13490

[Raineyb]

47. A lot of these new medicines aren't new at all

They make a small change for the purpose of being able to re patent the drug so they can charge exorbitant fees for it.

[mwooldri]

50. If prescriptions were free at point of delivery,

there wouldn't be a need for pharmaceutical companies to do patient assistance programs because they could get the medicines they need anyway!

Also, Glaxo Smithkline - one of the biggest pharma companies - is headquartered in the UK, and I *know* they provide grants to UK universities who do a lot of research projects FOR THEM, to the extent of funding the building of whole new chemistry and biology departments (this happened at the University of Dundee, where I went...). Providing grants to universities to make the discoveries, and for the medical hospitals to do the clinical trials through private and public funding drives down the cost of the research too.

Just remember where Dolly the Sheep came from.

Also with centralized medicine buying, you cut your marketing needs down from millions of people down to just one: the prescription medicine purchasing board (or whatever it would be called).

So that's a good few billion dollars cut out of the pharmaceutical companies' expense book. No need to market extensively, no need to give away the drugs for free, less need to do the more complicated research because the public sector can do that, and with publiclly funded medical schools, clinical trials can also be conducted at lower cost.

So new medicines would continue to exist and be developed, there just would be less money needed overall.

[OwnedByFerrets]

53. There are many experts in the field who disagree with your

assessment of this situation.

[crickets]

15. Exactly! -nt

[slackmaster]

20. Zing!

:hi:

[NashVegas]

25. No. That's Rationalizing

mwooldri points the better way: just say "no."

Too many people will not say "no." Too many people say, "I want that six months," hoping for miracle cure will crop up in the meantime. That refusal to say "no" is bankrupting all of us.

[NC_Nurse]

35. That was my first thought. Why the fuck does it cost 54,000?

[Spazito]

2. Geez, the author of this is a "prize"....

"The outrage was caused by Singer's belief that there is a case for euthanasia applicable to physically deformed babies, with all its echoes of Nazi eugenics."

"When, in 1999, Singer was given the chair at Princeton, not only did he face the demonstration of disabled people, but Princeton faced the removal of an endowment from businessman and publisher Steve Forbes, who said: "The elevation of Peter Singer to a place of honour in an endowed chair of bioethics troubles me just as it would if such an honour were bestowed upon an anti-Semite or a racist."

Marca Bristo, chairperson of the US National Council for Disability, said: "Singer's core vision that the life of a person with disability is worth less than the life of a person without a disability, amounts to a defence of genocide." Singer retorts: "It is always frustrating to be misunderstood, but I've had to put up with that for a long time." "



http://www.guardian.co.uk/books/2009/feb/15/peter-singer-profile

[Wapsie B]

4. Do they ration care in Canada or France?

[Spazito]

7. No, if you are need of care, you receive it in Canada...

with the exception of some elective procedures such as cosmetic surgery, etc. You receive care regardless of age or infirmity.

[Wapsie B]

36. The common conservative answer to that is that you'll wait for months on end for things like MRI's

and such. And it's not uneducated people spouting this nonsense.

[Spazito]

37. Yes, but the common conservative lies ....

and, thankfully, the facts are there to prove it. Education doesn't equate to honesty, it doesn't even mean intelligence.

[sharesunited]

9. Yes, but they also ration military interventionism.

[Wapsie B]

5. Do they ration care in Canada or France?

[glinda]

8. Not as I understand it.

[mudplanet]

40. Do they ration care in France

Well, yea. Everybody except people like Bill Gates gets rationed care, no matter where you live.

With a lot of diseases that lead to death, there is a lot that can be done to forestall the conclusion. If you're Steve Jobs and you get pancreatic cancer (which is invariably fatal) you can get all sorts of treatments including a liver transplant, and extend your life for quite some time. If you're the average, middle class person with good medical insurance, you'll get some chemotherapy to extend your quality time and then you die. If your my client, the unemployed homeless guy without a substance abuse problem but liver cancer due to Hep C contracted from a girlfriend ten years ago, you get offered some oral chemo, shown the door, and told good luck next time (liver transplant isn't even discussed despite the fact that the cancer hasn't metastasized).

If you live in Western Europe, and you get pancreatic cancer, you get pretty good care no matter who you are or how much you earn, but not to the extent that Bill Gates or Steve Jobs would get. You get a pretty good range of chemo drugs but maybe not the latest and the greatest. If your cancer hasn't metastasized they weigh all the factors (age, overall health, is there a twelve year old kid who needs that liver more) and consider you for a liver transplant. And you don't get a huge bill that essentially drives your survivors into penury - you've already paid for your care with your taxes.

If you're the European Bill Gates, you fly to Minnesota (or Switzerland or Houston) and get all the latest and greatest anyway but you can pay for it cash.

CreepJerk has a point when he says that we will have rationed care no matter what system we have and we have to accept that there are trade offs in how much we will spend to extend life or forestall death (I'm sure I'd live longer without the cigar or two a week, but man I enjoy them and they improve the quality of the life I have now). How are we going to decide on the trade offs (what treatments are worth it and what treatments aren't) is a good question. How about a committee of fair minded citizens? It's how we make decisions about other things.

So medical care is rationed in the United States, with the decisions made by underlings in insurance companies whose primary incentive is to deny you care so that they can get that big bonus or promotion.

And medical care is rationed in Europe, with the decisions made by civil servants and politicians whose primary incentive is to make decisions in the best interest of the public (which is why they've created a universal healthcare system to begin with, because it's in the public interest that health care be affordable and accessible).

But health care is rationed everywhere and for everyone except the super rich. And it's not free. I wish people would stop talking about free health care. It's like saying driving on the streets is free, or having a fire department is free. We pay for it with our taxes.

[vixengrl]

10. Singer is interesting (it's kind of militant utilitarianism--

a purely pragmatic value-assignation) and I think the point he raises is meaningful--

Any system that has to be worked out will require a trade-off, but the goal can neither be a "perfecct system that covers everything" (just not practicible) and can't be a rejection of changing the system, because our present system doesn't maximize our value. Rationing is---rational.

I don't care for the argument from the right that uses "rationing" as a boogeyman, because patently, rationing is already here. When an elderly person on a fixed income decides that, although the dosage of her medication should be three pills a day, but she cuts her pills and has one and a half a day because she might like to enjoy air conditioning and a bit of meat every now and then--is rationing, under our current system. Health care is being rationed by people who have recognized its cost to them can't be figured into their budgets. And this is a bad kind of rationing--it looks like personal choice, but it isn't, really. Our issue--like Skittles put it--is why would some medication cost $54K in the first place? Our costs simply are out of balance, and not just for exotic drugs that might temporarily prolong life.

Even completely mundane treatments that are proven to prolong life can be exorbitant. Also, unfortunately, our system is skewed because of its pricing and access structure in some ways to catastrophic, and not maintenance care. I think that it would be more cost-effective in the long run if we did more concentration at the wellness, maintenance care level--regular screenings, early detections, vaccinations, etc. It would benefit more people and lower costs--which might in turn actually free up resources for that exotic stuff. (The other boogeyman health-care reform critics like to trot out is that research will be hampered--bollocks. How many innovations have come from gov't grants? And who is to say private options for extra coverage couldn't still make up the difference?)

[vixengrl]

11. You know, without an OP, my answer feels pointless.

:(

[FourScore]

13. Thanks for letting me know. I reposted it.

Especially after reading your comments.

[Spazito]

14. I am glad you reposted it as well...

As despicable as I find this man's philosophy, his opinion WAS printed in the New York Times and should be seen in all it's 'glory'.

[Duke Newcombe]

16. We already ration healthcare...

In the U.K., it's rationed to the elderly.

Here, to the poor.

[EmilyAnne]

22. I agree.

[alarimer]

34. Yes we do.

But rationing will continue under any system. It simply cannot pay for everything. When it comes to end-of-life issues especially, it will be important to decide what is needed and useful.

Doctors order way too many tests as it is. Did anyone read that piece in the New Yorker a while back, in which the author looks at McAllen, TX and compares it to other, similar places? Well basically they spend more on Medicare in McAllen, not because people actually are sicker, but because doctors order too many test of dubious usefulness. They also own some of the hospitals and clinics to which they send patients to get those unneeded tests. So there is plenty of waste in the system already.

But if someone is terminally ill with cancer, should we really be paying for that hip replacement? I would say no. THAT is the kind of rationing I think we will need.

[Yavin4]

17. We Have Rationed Care Now

HMOs won't pay for certain treatments NOW!

HMOs decide what doctor you can see and for what treatment, NOW!

Healthcare is rationed NOW!

This is a false argument.

[subterranean]

18. Exactly, insurance companies routinely refuse to pay for treatments

that they deem "unnecessary." Is that not a form of rationing?

[area51]

38. Great post.

:thumbsup:

It always amazes me that people can't see we already have rationing, which I'm sure contributes to the death number of 273 people dying here per day due to lack of healthcare. This wouldn't be allowed to happen in a first-world, civilized country.

[pampango]

19. Everything is rationed, either by cost (have to have the money to obtain it), actual rationing

(coupon books like for gas in WWII), or the availability of funding for government to subsidize something (bread in the USSR, health care in Canada, etc.).

No health care system is going to allow me unlimited free trips to my doctor every day with medical complaints and request some surgery to deal with my complaint. I can't do that now and I won't be able (and shouldn't be allowed) to do that in any new health care system. There will be "rationing", it just needs to be just and fair, not based solely on the ability to pay.

[NashVegas]

27. I Wonder How Many CEOs Hear, "Sorry, Previous Condition."

And have to cough it up out of their own pockets?

[hedgehog]

21. On the other hand, if cataract operations had been rationed

40 years ago (why such an expensive operation for an old person who just sits around anyways?) would they be a routine out-patient procedure today? When I was a kid, people were kept in the hospital for at least a week, their heads held in place with sandbags, after eye surgery.

Ever have an MRI to diagnose a soft tissue injury? What about a CAT Scan? It wasn't that long ago that we were told those machines would bankrupt the system.

How many people live long, happy lives today because 30 years ago someone who was certain to die allowed doctors to try out a final treatment on them? It was expensive and just a little bit more of hell for the patient. Even though the patients involved were too far gone to be saved, medical science was advanced just that little bit.

We need to ration medical care based on the patient, not on the cost. Hip surgery for someone in end stage cancer can be as intrusive as being hooked up to machines. CPR is not for someone dying of end stage cancer or Alzheimer's. We need to support patients and families so they can let go when it's time. But it has to be their decision, not a blanket rule. Some 65 year old people are ancient, some 80 year olds are still young.

[NashVegas]

29. I Had Two MRIs

Ordered by an orthopedics Dr. One, I paid for out of pocked at $1k, and after that the insurance kicked in another.

After looking at the results, Doc said, "yeah, just as we thought, that's a cyst." And "yeah, just was we thought, you've got Achilles tendonitis."

In what world is that not fraudulent waste of my money and my insurance company's?

[hedgehog]

30. By any chance, are you out in Nevada? It's my impression

that medicine for profit is a bigger problem there than here in New York.


What did the MRI rule out? Was there a possibility of something bad that would have been missed without the MRI?

[NashVegas]

32. Nope

Nashville. Where HCA lives. And others.

No idea what it could have ruled out, that a regular X-ray or an old country doctor couldn't have.

An Dr. at an affiliate walk-in clinic of the same hospital once gave me four prescriptions when I came in with allergy-driven sinusisis. Nasarel (which was the only thing I was asking for), Allegra, something else I forget, and something else from the barbiturate family ("say, you get tension headaches, don't you?" no, not really. "I'm pretty sure you mentioned that before, are you sure?" yeah I'm pretty sure. "well I'm going to write you up for some somethingorotherital, see how that does for you.")

[hedgehog]

42. I think your experience is more evidence of the need to get the profit motive

out of helath care than it is of the need to ration. I wonder how many people without insurance are offered an MRI?

[City Lights]

24. You want rationing, Pete?

Start with Cheney. He's way over his allotment.

[yodoobo]

31. Your damn right its worth it

"may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?"

Where the hell is this ration healthcare bullshit coming from suddenly?

[ipaint]

41. To keep the for profit medical industry profitable care must be rationed.

Their obscene overhead and profits drive up price necessitating rationing.

[Techn0Girl]

43. There Are Two Sides.....

Firstly , you have to know that I am absolutely for a non-profit based solution to Healthcare in our country and that I believe that 100% of our citizens should be provided with adequate health care. Now with that said, you have to understand that Big Business is not the only problem we face with health care in our country. Let me explain ...

I know a 63 year old man who makes really bad decisions in his life. Because his parents were overly protective (or perhaps they needed to be) he vowed to do what he wanted when he grew up (which he never really did as you'll see below). So he refuses to eat any sort of vegetable or fruit whatsoever. His refrigerator is stocked with frozen pizzas, ice cream and sodas. He has had two heart bypasses in the last 10 years. He is 63 years old, diabetic, weighs 300+ lbs, has been jobless for 10 years now (never held jobs long anyway) and occasionally smokes. His refrigerator is stocked with ice cream, soda , frozen pizza, pork and other fatty meats - hich is his complete diet save for cookies and cupcakes for breakfast. Unbelievable, I know.

His main activity, unsurprisingly, is going back and forth to Kaiser (a popular HMO). He takes about 10 different medications a day and had little to no idea what they are for.

He has probably cost the HMO (I'm guessing here) probably between one to two million dollars so far the past 10 years with the two bypasses, the medications, the diabetes control and the weekly visits to keep him alive. He is well on his way to senility at this point (I'm guessing because of coronary artery disease and diabetes) and will likely spent the last few years of his life in a nursing him and cost even more money while he is there.

And it is all his fault and he doesn't care and he has never been willing to change.
And he is not alone.

I used to work in health care and stupid, ignorant and selfish people like the person I described were not uncommon. Such people took the majority of our time maintaining while others waited.

So while we're on the subject of rationing here...we also might want to think about not only the hundred million dollar executive selfish bastards who suck up all our money and resources but also the selfish bastards who sit in their lounge chairs all day eating nothing but ice cream and pizza (or beer) and suck up 20 times the resources that any one of us do. Because I can tell you from experience that there are tens of thousands more of them then there are of greedy executives.

We need to think about personal responsibility as well as corporate responsibility - and I believe we need to stop or limit in some way such selfish individuals as much as we need to stop the greedy corporations.

I'm hardly a corporate shill ( lol ) but I hope the above story makes some people think about all the things we need to correct in order to have a decent health care system in this country.

[Spazito]

44. Oh my....

Don't despise me but all I can do with this is



:popcorn:

[City Lights]

45. Dick Cheney...

...one of the selfish bastards who sit in their lounge chairs all day eating nothing but ice cream and pizza (or beer) and suck up 20 times the resources that any one of us do.

Cut his health care off now! The selfish bastard is over his limit. If he had made wiser choices in life, he wouldn't need so much care now. He's sucking up resources that could be used on hundreds of other people.

[Techn0Girl]

46. I'm really not sure of your point here...

Why would you initiate a thread bringing up such an interesting and controversial subject and then attempt sarcasm at someone who takes the time to post something relevant to the theme ?

What is the point of that ?

[abumbyanyothername]

48. What they are really, really afraid of . . .

is that once we all see how well it works to take profit, private enterprise and wall street out of health care, we'll start asking ourselves what the fuck we needs those components for in any socially useful process.

[crickets]

49. Ding! You got it. -nt

[bemildred]

51. We DO ration health care, you f*cking maroons. nt

[cap]

52. good. Give Up Yours First

eom

[anonymous171]

54. People still listen to that psycho? nt