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Rationing Healthcare — Unconscionable or Inescapable?


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In the current national debate over healthcare reform, the charge that certain proposals involve the "rationing" of healthcare is frequently heard. As usual in such controversies, imprecise definitions (or no definitions at all) cause much of the confusion. The attached article attempts to clarify the issue, but I don't offer it as a political commentary — I believe there's a lack of clarity among members/supporters of both major parties. The author, Peter Singer, is an Australian bioethicist and a visiting professor at a variety of institutions around the world. I'd be interested in hearing what others think of the article and the question:

http://www.nytimes.com/2009/07/19/magaz ... ref=health

Ned

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Ned

Interesting you should bring this up. I wrote a blog post on the article Monday. I'll state right up front that it frightened me. I am not a fan of the healthcare reform as it is currently proposed because I have seen no evidence that it would actually lower costs and am afraid that it will worsen care across the board.

Susan

The NY Times yesterday published an article from Pete Singer arguing for the necessity of rationing healthcare. It's a long article, but well worth the read if you want to understand the fallacious reasoning underpinning the argument for healthcare reform.

http://www.nytimes.com/2009/07/19/magaz ... are-t.html

The article begins with a discussion of the costs and efficacy of Sutent, a drug used for the treatment of advanced kidney cancer. It's expensive, as a lot of the drugs to treat cancer are. The question, as Singer frames it is "how much are we willing to spend collectively to extend a life by a few months?" He then approvingly discusses the British health care regulatory agency, NICE's, initial refusal to approve payment for the drug citing that the cost is not worth the benefit.

Nowhere in the article does Singer discuss the flip side of Britain's thriftiness: their cancer survival rates are among the lowest in the civilized world. I hardly think that the United States, where citizens currently enjoy the highest cancer survival rates in the world, wants to emulate the British health care system's approach to the treatment of cancer.

Singer's justification for his approving discussion of healthcare rationing is based on the following claim: "Health care is a scarce resource, and all scarce resources are rationed in one way or another."

Really? Singer offers no evidence to back up his claim, but it's an important one because it is one often used to justify Obama's rush to overhaul our entire healthcare system. It's also completely wrong. There is no scarcity of health care in the United States.

We have plenty of doctors, hospitals, clinics, and medical personnel in this country. There is nothing scarce about health care. It may be expensive, but that is not the same thing as being scarce. There may be places where there are few medical facilities or personnel, but it is not a nationwide scarcity by any means. Let's not forget that 84% of the US population has health insurance and access to health care. It is not the US that has long waiting times to be seen by specialists, or have access to imaging facilities or for elective surgeries. No, those items are scarce in countries like England and Canada with single-payer health care plans.

The argument that we need health care reform in this country because it is a scarce resource is not just mistaken, but fundamentally dishonest in framing the underlying assumptions for the debate.

Finally we get to the discussion of costs in Singer's article. Singer grossly overestimates the cost of the leukemia drug Gleevec in order to make his point. "For Medicare patients drug costs can be even higher, because Medicare can require a copayment of 25 percent of the cost of the drug. For Gleevec, a drug that is effective against some forms of leukemia and some gastrointestinal tumors, that one-quarter of the cost can run to $40,000 a year."

A quick search on the internet found a monthly cost of about $4,000 for 400 mg of Gleevec daily. The total cost would be $48,000--only a little higher than what singer cites as 25% of yearly costs. 25% of $48,0000 is $12,000. That's still a lot of money, but it's nowhere near $40,000.

Moreover, if Gleevec is covered under Medicare, it would be under a Part D plan because Gleevec is an oral medication. Checking the formulary for a pretty standard AARP Medicare part D plan, Gleevec, falls into the Tier 4 which has a 1/3 co-pay. So the initial prescription would be about $1,300. At $2,700 a Medicare recipient hits the doughnut hole and is responsible for 100% of the costs of the drug until out-of-pocket spending hits $4,350. At that point the catastrophic coverage sets in and the Medicare drug plan pays for 95% of Gleevec's costs, leaving a co-pay of about $200 per month. A Medicare recipient with a standard part D drug plan will pay about $9,000 yearly for Gleevec. Again, that's a lot of money, but it is nowhere near the $40,000 that Singer uses as a scare tactic.

To sum up, Singer's argument for rationing is based on (1) emulating the system in a country with one of the worst cancer survival rates in the world, (2) the lie that health care is a scarce resource, and (3) misleading figures involving the costs of specialized cancer drugs.

If you aren't alarmed by the rush to "reform" our health care system, perhaps you should be alarmed at the lies being told in support of the effort

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I just want to mention that since people are out of work etc. at most hospitals there has been an increase of people being seen in the emergency room and an increase of people being admitted for care. With these stats we also are having an increase of people not paying their bills. My point is we do take care of people without insurance, good care. We never just turn them away! What would be nice is if the government would recognize people and institutions who do and give them a break!

Donna G

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Knowing how hard Deanne fought to get Tarceva approved in UK's NICE health system I look beyond the obvious immediate health care issues and I am not too crazy about all of this myself!!

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Ned, I guess for me it depends on from what perspective I am answering. If it's me and I can gain a few months or years with a treatment, then no rationing. If, on the other hand, I use my head and answer from a realist perspective, then yes. But that is a qualified yes:

If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs

I have to ask, why does Sutent cost $54,000 and why did the Avastin I received cost $30,000 a pop. It is certainly an important weapon in the arsenal commonly used to fight cancer today. But it is seldom used alone. Why that price for a drug used in conjunction with other established treatments. Also, I was given it as a maintenance drug even though, to my knowlede, it wasn't scientifically established to work in that capacity. I'm not blaming the oncologists in this regard. They just want to give us every opportunity they can to live.

That's my rant. Don't really want health care rationed but do want some brakes put on cost by the pharmaceutical companies. I want to see what their CEOs and other top administrators are making before I buy the cost of research as a justification for outrageous prices on treatments.

Judy in Key West

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Judy,

There's another article in the NY Times today that deals with that very issue.

http://www.nytimes.com/2009/07/22/busin ... l?_r=1&hpw

The cost of target therapies is high for several reasons. First it is expensive to do the research and testing necessary to develop drugs and get them through the approval process. Second, these drugs have relatively small target polulations which means the cost of research development is spread over a much smaller population than for something with a much wider audience like a Nexxium or Celebrex.

On the other hand, you really have to wonder if REALLY takes $4,000 or more per month to recoup those costs and make a profit.

One thing is for sure, if these companies don't have the ability to recoup their costs and generate income there will be no more Tarcevas or Avastins coming into the market.

It's a hard issue to grapple with.

Susan

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Back in the day, the eskimos used to bring their elderly out to the tundra to freeze to death so they weren't a drain on the food supply during harsh winters...

The debate of rationing is the same thing. It is valuing one life over another based on certain factors. But they aren't MY factors.

Anyone who feels the nationalization of healthcare is a good idea, ask this question. Have any of these politicians who want to dictate the type of care you are to receive taken the hypocratic oath? Yet they will decide what care you receive.

How many of us here encourage our friends here who are fighting an advanced stage disease to fight with everything they have?

How many of us have encouraged a care giver of an 80 year old lung cancer patient to seek treatment if that is what the patient wants?

How many of us have commented on threads where doctors have said "why bother?" and we've said because you should have hope!!!

Is a nationalized health system is going to draw a line in the sand when your "end of life" is approaching...and decide that a person in that bucket doesn't get surgery...doesn't get chemo. Sorry, this is the single most devastating and scary political movement I've witnessed in my 34 years. I don't want the government telling me when it's time to give up hope.

And don't give me the "well you can have optional health insurance" arguement. It will cease to exist. Who has municiple trash pick up? Have you ever seen a private waste management company hired by your neighbors to pick up the garbage? No? Yea, well that's how scarce the private insurers will be when folks can get medical from the gov't for free.

Sorry...I'm ranting. But over the last two and a half years I have learned that an extra year can define a life time. Regardless of age.

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There was, when Mom was sick, an excellent website about the health-care debate that really looked at all the variables involved. Wish I knew if it was still up and running.

Rationing care, when I think of how many people, including Mom, would have been denied care based on prognosis, makes me sick to my stomach.

There has to be a better way to address the problem of so many Americans lacking insurance than this... And as one who is a recipient of 'free' health care with the military, I can tell you that while the price is great, MANY times the quality is lacking, and the waiting is long, and the process is frustrating.

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I am one who, most certainly, would be denied tx due to a dire dx and poor prognosis. Yet I am here almost 5 years later doing pretty darn well. Very simplistically ~ if you're old you won't be worth spending money on. Everyone will get a 'free' chest x-ray, but nobody will get the MRI or PET desperately needed. There's got to be a better way. wish I knew what it was ~ but what's out there is pretty darn scary to me.

Kasey

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Yea, well that's how scarce the private insurers will be when folks can get medical from the gov't for free.

Free? Last time I checked, even Medicare had co-pays. The VA health care I receive certainly does. I wouldn't consider a tax based system free any more than I consider the insurance at work (which undoubtedly robbed me of so many raises over the years as insurance rates kept rising) free either. One of the articles I read today astutely pointed out that one of the obstacles Obama has to overcome in selling his plan is the fact that most Americans consider their health insurance free, while we spend one sixth of the nation's economy on health care.

Any system is likely to leave some people battling and appealing for treatment when some doctor thinks it will do no good. For most of us in our current system, that means finding another doctor (hopefully one who's in your insurance company's plan so it won't bankrupt you - 60 percent of bankruptcies in this country are, after all, caused by medical bills; by the way, I'm probably about to experience that with my wife's cancer, but that's a topic for another thread). For me, with my VA health care, it's ranting and raving to the right people if I don't like the first doctor's decision. And so it might be in another government system.

Personally, I'm going to favor whatever system pays doctors a salary (like Mayo and the Cleveland Clinic do - but a salary based on how their patients do would be even better, I think), rather than paying them for how many things they can bill out, like most of our system does now. But, somehow I don't think that's how the proposed plan will work.

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Personally, I'm going to favor whatever system pays doctors a salary (like Mayo and the Cleveland Clinic do - but a salary based on how their patients do would be even better, I think), rather than paying them for how many things they can bill out, like most of our system does now.

Love this point!

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I agree it isn't "free" BUT talk to some "average" Americans...I've heard them make statements like "I can't wait to get my free health insurance".

So my statement was perception of those who are FOR it. I am against it and everything I've read shows the cost to be astronomical. We should all know there are no free lunches. Didn't mean to misrepresent. My intended point was the gov't option will squeeze out the private options.

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Well I can't disagree that the government's best intentions don't always work, either. The last time they tackled health care was a good example. Congress couldn't agree on anything else, so they just gave employers a tax credit for providing health insurance. That's how we ended up with employer paid health insurance. In essence, the government gave up billions in tax revenue from employers to subsidize health care.

But it ended up doing a great job of hiding the cost of health care. Wages since then haven't kept up with inflation, mostly because of the rise in cost of health care insurance, but no one seemed to figure out that health care costs were affecting what wages an employer could pay. They just kept enjoying their "free" health care, and had no idea about the true cost of it. I don't think there's any way we would have let health care costs get this out of hand without doing something if most of us had any idea about the true cost.

Now, with projections that health care costs could soon be a third of the economy, the government sets out to fix it. Good luck with all that, is all I can say. And we all get to live with the consequences of whatever they do.

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I love that we can actually have this conversation here!

Everyone makes great points and this can be a diving board for others to learn more, investigate and evaluate what is best for them and their personal situation and views.

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I heard on the news this morning the point that this "insurance" will not pay for "unnecesary" treatments. Who decides what is needed?

Also above there was a comment that Doctors should get just a salary , not get paid by the visit. That money not only pays the doctor but his office expenses, his office help, his rent, electricity etc. I do not want to be billed separately for who answers the phone , or makes my appointment, or bills my insurance company etc.

People think baseball players are worth millions a year ( basketball , football etc, entertainers.) The person who goes to college for years to get a doctorate degree, then does an internship, goes on to specialize with a residency. He should get $50,000 a year to pay for all that schooling and time, and for his office and office staff.

Interesting

Donna G

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Been wanting to post this since I recalled it yesterday. Stan has been saying for a long time that he'll be satisfied when we all get the same benefits as those guys on the Hill (in Washington). Bet if you told them that's what had to happen, they'd find something that worked.

Judy in Key West

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Well written, thought provoking article. I guess I just can't get my brain around the concept of the USA, my country, the richest country in the world, not being able to "afford" to take care of sick people.

If we eliminated insurance companies (and their overhead, advertising and CEO's ridiculous bonuses) and went with a single payer system that most of the industrialized world has had for 50 years, we would actually be spending money to take care of sick people. What a novel idea!

I guess I always subscribed to the notion that how a society treats its most vulnerable, its sick, its hungry, its poor, really shows what that society is really made of. Its physically revolting to know that right now there are people choosing between medecine and food while pharmaceutical companies and insurance companies are making billions.

Thats my 2 cents.

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and do something about medical malpractice Lawsuits!!! That's what drives Doctors malpractice insurance sky high!!!

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So many points...I'd like to give my 2 cents, but I have a buc fifty on this topic.

Randy, I agree, malpractice damages capped...costs would reduce. BUT Mr. Obama did NOT as part of this sweeping proposal propose capping malpractice damage awards...

RnR paddy. People do not get denied care in this country. You go to a doctor or a hospital, you will receive treatment. Drug programs sponsored by the pharma companies will address needs of those who do not have insurance.

And on the salary point...who is going to pay the salary? Every doctor in america will become a gov't employee??? And you think getting your license renewed at the DMV sucks...?

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Like others, I have a really hard time even thinking about making a decision if a person should live or die, based on their monetary status. I have a problem thinking about that mother that died because she decided to feed her children rather than buy her blood pressure medicine. I have a problem thinking about cancer patients that don't even have a fighting chance because they can't afford the "experimental" drugs that their insurance company won't pay for. So....I'm really confused about exactly where I do stand on the national health care issue. This is about a lot more than politics. It's about more than being a democrat or a republican. To me, it's become more about the ethical treatment of people. How many animal welfare organizations have I belonged to and supported in my life who were all about the ethical treatment of animals. Never, in my wildest dreams, did I figure we would be having a discussion about ethical medical care in the United States of America. As Nick said, it's one of the scariest things I have witnessed in my life and I'm older than Nick. Somewhere, rolling around in my head, the words "survival of the fittest" come into play. When herds of deer become so thick that there is not enough food for all of them to eat, hunters cull the herd...and somehow manage to make it sound humane, as a fast death is better than starving to death. By deciding who gets treatment, is this not exactly what we are doing? Will we withold treatment from the older, sicker of our population, since they are already doomed?

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Love all these points! And like Nick I have much more than 2 cents to say on this so I haven't really dived into this thread accept to agree with some really great points!

Oh, and on the point of who decides what's medically necessary? I was very pleased to hear in Obama's press conference that he would only support a bill where that decision was made only between a patient and their doctor.

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Ann, excellent post! I thank God that I am fortunate enough to have had all my medical bills paid so far at Mass General, (that's me knocking on my head) and I have not gotten any huge drug bills yet. But part of me will always rankle that I should have to be greatful to have something which should be a human right: quality health care.

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