If you have a right to health care, how much care?

By Maggie Mahar

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, she is fellow at the Century Foundation and the author of the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

Hat tip to Kevin M.D. for calling my attention to “The  Covert Rationing Blog,” where Dr. Rich offers a concise summary of the dilemma we  face as we move toward a consensus that health care is not a privilege, but something that every human being should have. (One can call that a “right” or a “moral obligation that a civilized society has to provide health care to everyone.”)

The point Dr. Rich is making is that once you decide everyone deserves health care, the question is “how much care.” As he puts it:

“Exactly how much health care are you entitled to  if you have a right to health care?  Do you have a right to certain  specified health care services, to a certain dollar amount of health care per  year or per lifetime, to  whatever health care it takes to achieve perfect health, or to some other limit or non-limit?

“The question of limits (whether we should have  them or not, and what should  they be) has been a central theme of this blog and of DrRich’s book. To reiterate the fundamental problem: 1) In America we believe that it is wrong to limit health care in any way, that  everyone is entitled to the very best health care, that any bit of health care that offers even a small potential of benefit should be provided, and that death itself is merely a manifestation of insufficient research (or actionable incompetence, or systematic discrimination against the  unwealthy, or corporate greed).  2) But against that closely held belief, we must balance the unremitting law of  economics which tells us that there is simply not enough money in the known  universe to buy all the health care that might potentially offer some small  amount of benefit to every person. Health care spending has to be limited,  or it will become a fiscal black hole.”

Dr. Rich is correct on all counts. Our American love affair with medicine — and in particular, medical technology — is all  tied up with our fear of death, and a feeling  in some quarters, that “American optimism” demands that to strive for immortality. We put such emphasis on the individual, and the individual ego; how can we accept that, someday, it will be extinguished? (I’ll always remember the doctor who told me, in an interview, “Of course, one day, most people will die.” I wonder who he was  excluding from “most people”? )

In my recent post on medical technology driving health care costs, I suggested  that we need to begin setting limits on that technology. This is especially true if we are aiming for universal coverage.

Here we need to recognize that covering everyone will cost more—much more. Some well-meaning reformers have suggested that  once everyone has access to care, we will save money because those who are now uninsured or underinsured will receive preventive care. The theory is that, today, the uninsured wind up in the hospital—where they receive very expensive care—because they didn’t get needed care in a timely fashion. I should acknowledge that in the past, I have made that very argument. 

But sometime over the past year or so, I have come to realize the ugly truth:  the uninsured die sooner than the rest of us. By leaving a significant portion of the population poor, and uninsured, we save money.

As the new Synthesis Project by the Robert Wood Johnson Foundation, “High and Rising Health Care Costs: Demystifying Health  Care Spending,” reveals, studies consistently show that when a large portion of the previously uninsured population  becomes insured, total health care spending rises by 10  to 13 percent.

Indeed, this report by the Center for Healthcare Systems Change (HSC) shows that, over the past decade, the decline in the percentage of Americans  who have insurance has slowed the rate of health spending growth. If everyone had been insured, our national health care bill would be even higher.

As Dr. Rich puts it, “steadily increasing the  number of uninsured Americans has become perhaps our most effective mechanism of covert rationing. This simple expediency alone goes a long way toward enabling us to avoid having to consider or discuss limits.”

This is because while preventive care will keep  some previously uninsured patients out of the hospital, they also will live long enough to fall victim to very expensive diseases like Alzheimer’s, and certain cancers. Moreover, the previously  uninsured, like the rest of us, will be overtreated. Unless universal coverage includes some very intelligent rationing, that many more people will receive  unnecessary tests and scans, leading to unnecessary procedures.

This, of course, is not a reason to leave a large segment of the population uninsured.

But it is a reason to take Dr. Rich’s argument seriously. Now that we seem to be reaching agreement that we no longer want to ration care according to ability to pay, we will have to begin discussing how to ration care some other way.

It seems reasonable to begin by refusing to pay for treatments that are only marginally effective, giving the average patient only a few extra months  of poor quality life. But if “on average” patients live only a few months longer, that means that a few patients will live nine months longer. And we cannot know we they will be. Yet our resources are finite.

It strikes me that before we pour vast sums into customized medical care based on genome research, we might ask whether we, as a society, will be able to afford such care. Or will this be medicine only for the wealthiest few?

Perhaps rather than focusing on technological progress, we should focus on harnessing the technology that we have now so that we can understand it better, and use  it more efficiently, for the benefit of the  population as a whole. After all, what is the point of universal coverage if we  cannot afford to provide universal care?

All of this winds back to our vain effort to somehow “beat  death.” We keep pushing the envelope, in hopes of living longer. But living longer only means dying of something else. And, too often, it means that the body outlives the mind. Wouldn’t it be better  to aim for a higher quality of life, for all of us, for eight decades, or perhaps nine — rather than striving to see how many of us can totter over the finish line at 115.