In Health Insurance, We Cannot Have Everything All of The Time

Before passage of the Affordable Care Act (ACA), some of the bitterest arguments focused on the potential for death panels  that would set treatment policy, deciding which patients and which medical conditions would receive which kind of treatment, if any.  Within the scope of those rationing decisions, some feared older patients would be denied aggressive or costly treatments and that patients with rare diseases (that may be best treated with an “orphan drug”) may be assigned to just palliative care.  We seemed to ignore that health care was almost a “right” for most seniors, children, veterans, and those incarcerated.  For the rest of us, health care access was rationed by our employer’s policies or our own ability to pay.

ACA’s proponents pointed to national health coverage available in other countries as an example of the level of universal compassion that we in the US should aspire to.    Simultaneously, opponents of ACA pointed to rationing by the national health coverage countries that resulted in unacceptable shortages or delays in treatment.

While some wish otherwise, there are limits to the portion of our resources that can be spent on health care.  If we go beyond the limit, we constrain what consumers can allocate to defense, housing, food, transportation, education and public order.  Despite that, and since it is far easier for a politician to promise “plenty” rather than “scarcity,” we must expect that some will insist that any replacement for ACA offers treatment coverage the same as under ACA, and patient eligibility the same as under ACA.

A budget that supports “everything for everyone” plan will never be available.  Inevitably, treatment shortages and rationing will show up in any realistic “repeal and replace” effort.   What may distinguish us from other national health plans is merely the criteria used to determine what and who is subjected to rationing.  Some national plans include moral judgements that restrict who and what treatments are covered.

UK’s National Health System allows 211 “clinical commissioning groups” to control the budget for healthcare and decide who can receive what treatment.  Through these rationing decisions, their medical practitioners seek to devise the best allocation for scarce funds.  The availability of counselling, cataract surgery and fertility treatment has been tightly rationed in many UK areas resulting in long delays before treatment.  The rationing falls heaviest on identifiable groups.  More recently in Yorkshire, patients needing surgical treatments can be pushed to the end of the long queue if they do not cease smoking or if they remain obese.  That “end of queue” penalty is consistent with the judgement that obesity and addiction (e.g. nicotine) are the result of bad behavior more than they are a disease innocently acquired.

On the other hand, the U.S. Surgeon General has declared addiction to be a disease and that addicts require substance abuse treatment,  presumably not by assigning them an end of the queue priority.  In contrast with this declaration, six months earlier a Harvard Medical School study concluded “20 to 40 percent of cancer cases, and half of cancer deaths, could be prevented if people quit smoking, avoided heavy drinking, and kept a healthy weight.”  The same judgmental epistle is heard from many Americans.  Evidently, they and Harvard did not get the talking points memo absolving us from personal responsibility.  Self-control and self-reliance used to be universal expectations, but those expectations have been lowered by our political leaders.

Delayed treatment is a rationing strategy in some countries.  In Canada, the single payer system has developed a vicious clinical habit of acknowledging patient problems yet consigning them to wait times of several months for an imaging study or six months for surgery.  Canada’s spending on health care is not especially stingy, but it is just focused away from high tech treatments.  Wealthy Canadians in a hurry can get immediate sophisticated medical care from the US, or they can enjoy leisurely medical tourism in sunny places such as India or Mexico.  These alternatives act as safety valves that relieve some of the frustration with intransigent politicians over Canada’s outrageous medical delays.

While some health care insurers would rate health risks by including obvious lifestyle risks, the ACA arrangement abandoned consideration of how risky a patient has chosen his life to be.  Oil rig workers, sky divers, rodeo cowboys and loggers do not pay a higher risk premium to distinguish them from kindergarten teachers or bookkeepers.  Under ACA, those who choose high risk jobs and hobbies are subsidized by the rest of us.  A plan structured to accommodate such implicit subsidy welcomes avoidable costs.  Likewise, a viable plan could avoid elective treatments such as gender changes, IVF and life-extender treatments that are not clearly cost justified.  There is useful bias toward favoring treatments based on how much they improve patients’ health, rather than how many pills are sold.

The cost savings role for efficacy, self-control and avoiding high risk behavior may appeal to the public.  Any new health care plan must balance who and what are covered at a cost that all can afford.  No matter what we call it, rationing will be part of the mix.

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