Massachusetts has a long track record of making headlines in the area of health care reform, whether or not Mitt Romney likes to talk about it.
In 2008, Massachusetts released results of its initiative requiring virtually all of its citizens to acquire health insurance. In short order, nearly three-quarters of Massachusetts' 600,000 formerly uninsured acquired health insurance, most of them private insurance that did not run up the tab for taxpayers. The use of hospitals and emergency rooms for primary care fell dramatically, translating into an annual savings of nearly $70 million.
But that's pocket change in the scheme of things, so the other shoe had to drop -- and now it has. Massachusetts is back in the news, this time for passing legislation that aims to impose a cap on overall health care spending. That ambition implies, even if it doesn't quite manage to say, a very provocative word: rationing.
Health care rationing is something everyone loves to hate. Images of sweet, little old ladies being shoved out the doors of ERs that have met some quota readily populate our macabre fantasies.
But laying aside such melodrama, here is the stark reality: Health care is, always was, and always will be rationed. However much people hate the idea, it's a fact, not a choice. The only choice we have is to ration it rationally, or irrationally. At present, we ration it -- and everything it affects -- irrationally.
I can tell you from a doctor's perspective exactly why this matters. Some years ago, I was volunteering as a supervisor for medical students providing outreach in a homeless shelter in New Haven, Conn. I met a woman in her early 30s who was severely limited in her activities by shortness of breath, and listened to her story.
Months earlier, she had a brief illness and spent a few days in bed. When she got better and back on her feet, she noticed she had a pain in her left calf. She thought about seeing a doctor, but had no insurance and couldn't afford to go. So she just hoped the pain would go away.
It didn't; it got worse. But she didn't seek medical attention because of cost; it simply didn't hurt enough to justify spending money she needed for food.
Until suddenly, late one night, she found herself gasping for breath with stabbing chest pain. Naturally, she wound up in the emergency room via ambulance, and then the intensive care unit. She was diagnosed with a pulmonary embolism, a blood clot in the lungs. This condition can be fatal, and in her case, nearly was.
The source of a pulmonary embolism is usually a blood clot in the leg. In this case, that's just where it came from -- a blood clot causing pain in the left calf. When a clot in the leg is detected and treated early, a life-threatening pulmonary embolism is entirely preventable at fairly low cost.
This woman, a mother back then of a 3-year-old daughter, would never fully recover. Her health care costs ran to hundreds of thousands of dollars, a bill for the hospital, and by extension, the taxpayers -- namely us -- to pay. She had no means to pay it -- and didn't ask for the care in the first place. The shelter called the ambulance.
By denying this woman access to care she needed, or public insurance that would have paid the nominal costs of early care, our system resulted in both ruined health and a much bigger bill.
Unfortunately, I can tell this tale from a personal perspective as well. Some time back, a family member -- a healthy man of 32 -- noticed a discoloration on his skin, and saw a doctor. The doctor recommended that he go to a dermatologist. But just then, this man was leaving one job and looking for another. Naturally, that meant he was temporarily uninsured. So he decided to wait for his new job and his new insurance.
Some months later, with a new job, new insurance, and newly married, the man went to the dermatologist. He was diagnosed with malignant melanoma. It had grown since his first doctor visit, and try as they might, the surgeons could not get all of it. Following cycles of chemotherapy, the man died at age 34. Tragically irrational rationing.
In cases like this, people are paying with their lives for the gaps in our insurance system, something the health care reform of the Obama Administration at least partly addresses. There are costs to fix those gaps, yes -- but there are higher costs in not doing so. A skin biopsy is a minor expense. Extensive surgery and cycles of chemotherapy are enormously expensive, to say nothing of the economic toll of a working, productive young adult becoming a debilitated and dying patient.
In a system of universal, or nearly universal health insurance such as in Massachusetts, decisions about what benefits to include for whom are decisions about the equitable distribution of a limited resource. If that is rationing, then we need to overcome our fear of the word so we can do it rationally. By design or happenstance, every limited resource is rationed. Design is better.
In the U.S. health care system, some can afford to get any procedure at any hospital, others need to take what they can get. Some doctors provide concierge service, and charge a premium for it. Any "you can have it if you can afford it" system imposes rationing, with socioeconomic status the filter. It is the inevitable, default filter in a capitalist society where you tend to get what you pay for.
That works pretty well for most commodities, but not so well for health care. As noted, failure to spend money you don't have on early and preventive care may mean later expenditures that are both much larger, and no longer optional -- and someone else winds up paying. If you can't afford a car, you don't get one; if you can't afford care for a bullet wound -- if you can't afford CPR -- you get it anyway, and worries about who pays the bill come later.
But those costs, and worries, do come later -- and somewhere in the system, we pay for them.
By favoring acute care -- which can't be denied -- our current system of rationing dries up the resources that might otherwise be used for both clinical preventive services and true health promotion. Fully 80 percent of all chronic disease could be eliminated if our society really rallied around effective strategies for tobacco avoidance, healthful eating, and routine physical activity for all. But when health care spending on the diseases that have already happened is running up the national debt, where are those investments to come from? The answer is, they tend not to come at all. And that's rationing: not spending on one thing, because you have spent on another.
Nor is this limited to health care. The higher the national expenditure on health-related costs, the fewer dollars there are for other priorities, from defense, to education, to the maintenance of infrastructure. If cutting back on defense calls the patriotism of Congress into question, then classrooms get crowded and kids are left to crumble. Apparently, it is no threat to patriotism to threaten the educational status of America's future. Whatever...
The resources we ration may be laundered in such a way as to make the rationing invisible. Those little old ladies never actually do get shoved out the ER door -- or if ever that does happen, it's both illegal and a scandal that makes headlines. But our kids may well wind up in overcrowded classrooms with outdated textbooks, because the money ran out. That, too, is rationing.
Massachusetts has thus embraced nothing other than the inevitable in proposing that health care costs be capped. Colleagues and I went further in a program we called EMBRACE, published in the Annals of Internal Medicine in 2009. We actually suggested a rational approach... to rationing. For any hope of ever moving in that direction, we have to "embrace" the reality of limited resources and stop wincing every time we hear the word. All finite resources run out, and all resources are finite. We have to stop running away from this fundamental reality, and deal with it. No little old ladies waiting in the ER need be harmed in the process.
The more we spend on acute care, the less we spend on prevention. But also, the less we spend on other things that matter -- like books for our kids in school. The less we spend on books, and teachers, the lower the literacy rate. The less our literacy, the less our society is able to read the writing on the wall.
Right there, in bold lettering for those who can read it, is the time-honored message that rationing is inevitable. Whether rational, or irrational, however, remains a choice we can make. Here's hoping the experiment in Massachusetts may help show us how to make it wisely and well. Minimally, here's hoping it helps us stop running from the only reality we've got.
-fin
Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org
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T. Berry Brazelton, MD: Speaking Up for Children
Susan Blumenthal, M.D.: Healing America's Health Care System
Jason Alderman: What Health Care Reform Means to You
Kathy Lim Ko: Starting This Week: Affordable Preventive Care for Millions of Women
http://www.propublica.org/article/to-stent-or-not-to-stent-that-is-in-question
One cannot expect politicians or govt to provide leadership or monitor the progress in every field of daily life. Yet, govt through false financial incentives and social engineering efforts has distorted all aspects of American life.
Solution moving forward is "Starve The Beast" and demand "more bang for the buck". Where is our American ingenuity? Solutions should come from those who work in the particular system rather than from Washington. Individuals in current leadership positions should lead, follow or get out of the way.
In healthcare, challenge is to eliminate the current 30% of over-treatment and inappropriate treatment; which has been so well documented in the Dartmouth Atlas of Healthcare. Best people to weed out over-treatment is local doctors and hospitals; with Govt / insurance carriers providing them (and the community) real-time statistical data of inappropriate care.
I'm convinced that done right, we'll be rationing and ultimately eliminating over-treatment and inappropriate care; along with myriad of human parasites, (not involved in delivering care) that have inserted / injected themselves in the delivery of medical care.
What we have to realize, and we don't like it, is that all goods and services are finite and therefore have to be "rationed." That is what all economic systems are ultimately all about. For some, maybe most, the market system works fine. For health care it does not, for the reasons you pointed out and others.
The fact that policy makers don't really care about health outcomes or costs of care is demonstrated by the fact that "80 percent of all chronic disease could be eliminated if our society really rallied around effective strategies for tobacco avoidance, healthful eating, and routine physical activity." Government policy provides the greatest subsidies to the least-healthful food products, and then it provides subsidies to the poor to consume these unhealthy foods to their hearts discontent. To suggest medical costs are diverting resources from our ability to change these policies is absurd. There is simply no political will to enact rational and purposeful policy.
If the elite cared about people the world would not be in this state.
Preventitve care is cheap and easy. Free walk in clinics. That would take much profit from hospitals and insurance.
Naturally, this state command and control direction of health insurance spiked the overall cost of medical care and health insurance to cover it.
The state can no longer afford its Medicaid and businesses are howling over the cost of health insurance from the 2-3 surviving companies which have not yet left the MA market.
In true socialist fashion, MA is now attempting to fix the market consequences of Romneycare with another mandate seeking to impose a cap on the amount of health care medical providers can provide:
"It will establish a commission to monitor the growth in spending and require that health care providers or insurers explain themselves if their costs rise above the target growth rate. If there is no valid reason, the commission can demand that an organization submit a plan to bring its spending back in line. As a last resort, the commission can impose a $500,000 fine if it finds that the organization failed to make a good-faith effort. Many analysts expect the state will have to become increasingly aggressive in demanding cost cutting by providers and insurers if savings do not materialize."
http://www.nytimes.com/2012/08/05/opinion/sunday/massachusetts-takes-on-health-costs.html?_r=3&emc=eta1
This is the future of the rest of America if Obamacare is not repealed.
Banning tobacco products and replacing them with nicotine delivery devices would save billions in health care costs. But Republicans would run ads showing tobacco farmers with tears running down their cheeks as their farms are being auctioned away, decrying our loss of "freedom." The public has to suffer in order to protect the jobs and profits of an evil but politically well connected industry.
In a truly free society, you have to pay for your own health care. If you live like a pig, your life is short and unpleasant.....and nobody misses you when you're gone.
The vast majority of people don't want a "truly free society" because they aren't sociopaths.
Family members and friends who do not take care of themselves cost tens or even hundreds of thousands each to the taxpayers and the other policyholders.
Not fair. But I won't for a minute give up my healthy ways, so long as I can afford it.
We won't save healthcare costs or improve health outcomes by wasting money on ineffective philosophies and pseudo-science. If it works, then there will be evidence to support it - and therefore support spending public resources on it.
1) Medicare-for-all at the state level with the federalism of subsidies in the ACA. The issue is not really sick people but rather the need to have the medical facilities when they are needed. There are three different business models here; rural, suburban and urban.
2) The delivery system is fixed by using Peter Orszag's “Best Medical Practices”, interactive-electronic diagnostic and treatment workbooks and a smartphone.
http://www.huffingtonpost.com/social/no_body/obama-affordable-care-act_b_1389760_144757327.html
References:
http://www.huffingtonpost.com/social/no_body/obama-affordable-care-act_b_1389760_144771932.html
The diagnostic workbooks would come back with an efficacy, statistical prognosis and cost to the patients for all the different treatment options so they can make an informed choice.
3) Health care rebates for shopping around, positive living, etc. Similar to the way rebates work for car insurance. It would be based on the statistical normal cost of treatment for all the different therapies. Offering quality-of-life at the end-of-life. Although open to abuse it could be tightly controlled.
4) Not letting Medicare negotiate prices is a sin. But the workbooks could have registered steps in them that would allow a business model like a 900 number. Therefore innovation is not limited to producing a pill but only a better outcome.
lost their holdings in teh Company. . Obama says he has saved GM and wants to save all the rest of the companies. He wants to take over basically is what it is. GM owes us taxpayers $42Billion Dollars and he forgave them 3 Billion of it and they are exempt from corporate taxes. So let's let the Goverment run it all, that's what's is irrational..
We need good government and more of it.....I trust the medicare system and I'm not old enough for it yet, but it worked very well for my Dad before his death and it works very well for my mom.....blue cross/blue shield as one example cares nothing about people, profit is their only concern.
A tax, not a tax, blah, blah, blah, nothing more than bs talking points....we need a health care system that works for everyone, sooner rather than later....most of us aren't ever going to receive the excessive, expensive and unlimited care dickcheney does, but we shouldn't have to die too soon either because even though we work we can't afford the luxury of health care....unfortunately we spend more time arguing than trying to find solutions of any kind for any of the massive problems facing our country....
What a marvelous right wing paranoid delusion. Did you get that from Glenn Beck?