Sun, 07/05/2009 - 8:21am — lambert
Let me remind rationing-phobes what they would find in the huge body of research literature and media reports on our health system, should they ever trouble themselves to read it:
- Many Americans without health insurance or very high deductibles routinely forgo prescribed medicine or follow-up visits with a doctor because they cannot afford it, risking more serious illness later on.
- A 2008 peer-reviewed study by researchers at the Urban Institute found that health spending for uninsured nonelderly Americans is only about 43 percent of health spending for similar, privately insured Americans. Unless one argues that the extra 57 percent received by insured Americans is all waste, these data imply rationing by price and ability to pay.
- A few years ago, The Wall Street Journal featured a series of articles reporting how often uninsured middle-class Americans are charged the highest prices at pharmacies and in hospitals, and how sometimes they are hounded over medical bills to the point of being jailed for failed court appearances.
- Studies have shown that solid middle-class American families — even ostensibly insured families — can lose all of their savings and sometimes their homes over mounting medical bills in the case of severe illness.
- In its report Hidden Cost, Value Lost: The Uninsured in America, the prestigious Institute of Medicine a few years ago estimated that some 18,000 Americans yearly die prematurely for want of the timely health care that health insurance makes possible and that can prevent catastrophic illness.
- A recent study by an M.I.T. professor found that uninsured victims of severe traffic accidents receive 20 percent less health care than equivalent, insured victims and are 37 percent more likely to die from their injuries.
Need I go on?
Single payer would solve all this, including the 18,000 deaths. Everybody in, nobody out.. "Public option" (or "plan") advocates can only ameliorate them. The burden of proof is on them to show how they can address these problems and prevent those deaths.
NOTE Via Baseline Scenario, which you should be checking daily, if you are not already.
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On "irrational rationing", see Maggie Mahar's book
Money-Driven Medicine.
Mahar describes our "system" as "irrational rationing". In her chapter "Too Little, Too Late: the Cost of Rationing Care" she gives an expanded version of Reinhardt's point here with many of the same sources.
Here's Mahar's example of why our present way of rationing care is not only unjust but irrational: in 2003, Oregon's state legislature decided to save money by discontinuing prescription drug coverage for some of its Medicaid patients. As a result, a seizure disorder patient stopped taking his medication ($14/day in 2003). Assume the patient, in his mid-30s, had lived another 50 years: then in 2003 dollars the total cost would have been $255,500. Without his medication he had a grand mal seizure, ended up in intensive care for "several" months, then in a long-term care facility, where he died in November 2003. We don't know the total cost of this treatment, only that the ICU care cost over $7500/day. Ninety days of this would cost $675,000. That doesn't count the long-term care cost, the emergency room cost, the economic repercussions on his family and community, let alone the value of a person's life.
Mahar's overall point is that what we have is "ad hoc rationing", no "system", just the invisible hand of the unfree market. "Hospital workers are being forced to ration care on a case-by-case basis." Robert Perry, CEO of Philadelphia's Northeastern Hospital ssays "Health care is all backwards in this country. The biggest decisions are all made in the worst conditions." (quoted by Geeta Anand in the WSJ in 2003, "The Big Secret in Health Care: Rationing Is Here", September 12, 2003).
Some prefer our way even while calling it "muddling through". They prefer to avoid explicit conflict over resources, "acrimony", and "political mobilization". (Hmmm, what does this remind me of?)
Mechanisms for irrational rationing (some are mentioned by Reinhardt):
Mahar goes on to point out that all this is not the result of hospitals being run by nasty heartless people. Even "not for profit" hospitals still have a duty to their investors. NYU Medical Center, which received $4 million from the state in 2003 (?) responded to a request for information about NY state charity care funds by saying "NYU Hospital is a corporation, people have to pay for the services they receive here...if they can't pay, they have to just get the hell out!"
It's the (non) system as a whole that results in reducing poor people's need for care to a hot potato. "Hospitals try to pass the costs onto private insurers; insurers, in turn, shift costs to employers by lifting their premiums, while employers pass on the hikes to employees." John Kitzhaber, a former emergency room doctor: "These actions are apparently based on the assumption that if we simply stop paying for people's health care needs, they will somehow go away and as a society we can avoid the cost. But this only works if you are also willing to ... let people die on the ambulance ramp for lack of insurance coverage."
And for the story that brings it all together and breaks your heart and makes you sick with anger and fear, see pp 212--214.
Policy not party!
it's a good book
the problem with maggie mahar is that she's wildly inconsistent. on her blog, she has both said that medicare-for-all is ultimately the best solution and then turned around and at other times accused single payer advocates of spreading misinformation when we say that medicare for all is the best solution.
she's very much in the camp that [1] worships the dartmouth atlas, which is based on medicare claims data [as opposed to actual treatment data], and [2] interprets the dartmouth data to mean that people in lower-spending regions of the country are getting excellent care while people in higher-spending regions of the country are getting bad care and that [3] therefore what we need to do is stop those greedy people in the high-spending regions from using up all that extra care.