Preventive Medicine Column September 23, 2007 The More Rational Rationing of Health Care

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Preventive Medicine Column

September 23, 2007

The More Rational Rationing of Health Care
Finding a way to provide health insurance for all Americans is fast becoming almost as prominent an issue in the presidential campaign as the war in Iraq. And rightly so; 1 in 6 Americans lacks health insurance. But as candidates, one by one, reveal their plans for addressing this crisis- Hillary Clinton most recently- they are reluctant to propose the obvious solution, universal government-funded healthcare. That reluctance is in deference to two deep-seated American fears: big government, and rationing.

I’ll leave the topic of big government versus small to someone else, other than to note there is a limit to how “not big” a government actually expected to govern 300 million people scattered across 4 million square miles can be. My interest is in rationing, and the fact that we seem more afraid of the word than the deed.

Make no mistake, we are currently rationing healthcare in the United States. And we are doing it 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, CT. 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. Until suddenly, late one night, she found herself gasping for breath with stabbing chest pain. Naturally, she wound up in the emergency room, 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.

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 tax payers –namely us- to pay.

By denying this woman the insurance that would have paid the nominal costs of early care, our system resulted in both ruined health and a much bigger bill. Folks, that is penny wise, and pound foolish. It is irrational rationing.

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 system. There will be 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.

The fear that insuring everyone will result in rationing of healthcare services is misguided. We are rationing those services already, but in the most irrational of ways. By denying early and preventive services, and paying the much higher human and financial costs of late-stage, emergency care, we are squandering money, our principles, and human potential.

In a system of universal health insurance, 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.

And for what it’s worth, treating health care as a right rather than a privilege does not require that it be a handout. Rights and responsibilities routinely go together, and there is no reason why healthcare should be different. A license gives you the right to drive a car, but you have to show up at the DMV and renew that license periodically. To keep your license, and the rights it confers, you have to abide by the rules of the road.

A universal license to access the American healthcare system could similarly come with some rules. My suggestion is we guarantee health insurance for all, but require in return that it be put to good use. Clinical preventive services, such as immunization and cancer screening tests, reliably translate into both better health, and lower costs, but are underutilized. The right to access such services at no or low cost could quite reasonably be tied to the responsibility of doing so.

Our values say that healthcare is a right. Our system treats it as a privilege. Our fear of rationing perpetuates this high-cost status quo. That is, in a word, irrational.
Dr. David L. Katz;
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