Don Berwick, possibly the most widely respected and thoughtful expert on improving health care quality and controlling health care costs, has withdrawn his nomination as head of Medicare in the face of Republican opposition based on claims that Berwick wants to ration the availability of health care. Which is intellectual horse manure if you honestly consider all of what Berwick has written and said and done. But to whine about politics interfering with a presidential nomination is pointless, and misses the more important question. Why do people who believe in the rationality of the market about prices and supply and demand so ferociously oppose just that if you change rationAL to rationING?
Suppose you have a disease... an incurable fatal disease... and a drug has just been approved that can treat that disease. The drug only works in about half the people who get it, and all it does is lengthen their lives by an average of 4 months. Side effects include diarrhea, nausea, rash, and fatigue. Still, you couldn't get your hands on it fast enough.
But suppose the drug costs way more than you can afford, and suppose that insurers won't cover it because, they say, the drug does not provide 'cost-effective' use of health care dollars. Cost-effective!? How DARE they! How DARE some number-crunching, penny-pinching, cold-hearted bureaucrats decide what you can and can not have that might lengthen your life!!!! How dare they decide who lives or dies, based on money!!!
Welcome to the United Kingdom, where the government oversees the health care system, and where the National Institute for Clinical Excellence (NICE) that reviews drugs and treatments for the government recently recommended that the $126,000/patient cost of Yervoy, a new drug that can prolong the lives of some people with advanced, inoperable (and usually fatal) melanoma, is too high and that it doesn't provide enough health care bang for the buck so the National Health Service (NHS) shouldn't cover it. If the NHS takes that NICE advice, some people in the UK with advanced inoperable skin cancer who can afford Yervoy may live a little longer. Some who can't afford it, will die... a few months sooner than they might have.
Ugly, huh, putting a monetary price on life? But now let's change the shoes you're wearing. Let's say you're not the patient. Let's say you're in charge of the health care system, and you're asked to choose whether to cover a drug that can treat some terrible fatal disease, but which only prolongs life by a few months, and only in half the patients who get it, and many of the patients who are helped live those extra few months vomiting and weak and covered in a rash. And the drug costs so much, per person, that approving it for coverage will mean insurance rates for everybody in the entire system will have to go up, to cover the costs. Now what do you think?
To a patient, approving or disapproving coverage of health care based on a comparison of costs against benefits is rationing, in all that word's ugliest meanings... 'denying choice' and 'death panels' and 'murder.' But to everyone suffering in one way or another from the excessive cost of health care -- which is most Americans -- this sort of decision making is rational, in all the positive meanings of that word... wise, thoughtful, balanced and fair. Interesting, isn't it, how the tiny difference in those two words -- 'rationing' and 'rational' -- belies the great gulf between what each implies. In that gulf lies the heart of the difficulty in solving the health care cost crisis.
It's pretty obvious that the system can't afford everything. Analysis of health care benefit per dollar of cost is one way the UK and other health care systems are using to face that reality. The U.S., where 'freedom of choice' and 'land of opportunity' are so intrinsic to our self-identity, has not found a way to confront such tough choices. So:
- We spend more than twice as much per person for health care -- $7,538 -- as the average of all the other industrialized nations -- $3,060.
- More than one dollar in four that the average American family earns (median income -- $50,000), goes to health care! (average family health care spending -- $18,000).
- From 1999 to 2009, the inflation rate for health care in the US rose 60% faster than inflation in general.
There are many reasons for this crisis; the way doctors and hospitals are paid (per procedure, incentivizing more care), the costs the uninsured create when they get emergency room care everyone else has to pay for, obtuse billing systems that hide the true costs from the consumer. True as all these reasons are, they fail to recognize the core truth that lies at the heart of the health care cost crisis, the real reason we have not had the courage or wisdom to find a way to make hard choices... the reason why 'rationing' and 'rational' can feel so night-and-day different.
Comparing costs and benefits may be rational, but human risk perception is not. The way we judge danger, and figure out how to keep ourselves safe and alive, is not a purely fact-based, coldly objective process of cognitive analytical reason. It is a subconscious, instinctive, emotional process, the principal objective of which is not to serve some greater common good, but to keep each of us alive. The 'thinking' part of our brain may accept that the system can't afford everything for everybody, but the thinking part of our brain is only one part, and not the most influential part, of the way we figure out threats to our health and safety. Ultimately risk perception is a mix of the facts and how those facts feel, and the brain puts more emphasis on the feelings than the facts.
And so rationing, as much sense as it might make intellectually, upsets us because it threatens us. It literally viscerally threatens us. Never mind that the health care cost crisis threatens us too. Those threats -- to our ability to afford the comprehensive health insurance that would give us access to every medical option, to our family budgets, and to the prices of all the goods and services produced by businesses who pass along their cost of providing health benefits for workers -- don't seem as immediate, don't feel as real, don't feel as threatening, as it feels to have advanced inoperable melanoma and to be told that the government won't help you pay for a drug you can't afford, that could prolong your life.
So what will it be? Freedom of choice or rational rationing? Yervoy (and any drug or treatment that has even minimal benefit) for all, and the expense be damned? Or prioritizing coverage for care that yields the most health bang per buck, because otherwise, the cost of the health care system -- which we all have to pay one way or another -- will create bigger and bigger risks of its own? Until the debate about the cost of health care in America honestly confronts that choice -- and the realities of human risk perception that make it such a difficult choice -- we won't be on a path to true solutions.