Singer, Peter - Why We Must Ration Health Care

07/24/2009

New York Times, July 19 2009

This is a magazine article for the popular press dealing with the ways to assign value to public health. The article concludes that health care rationing already takes place and that instead we should enter into a conscious public conversation about how to find value with health-care dollars.

The article starts with an example of a drug that had been developed extend the life of terminal kidney cancer patients by maybe 6 months or so. The cost was $54,000. Would you pay for it? Would you want to be paying premiums for an insurance plan that pays for it? The article plays on the difference between the personal choice that you might make compared to the public-health choice that we collectively make. When using public funds to pay for treatments, author argues that it is 'crazy' not to ask for good value, which is equivalent to rationing.

The other argument here is that the US system also rations, but instead of doing so through a bureau, through one's ability to pay for treatment privately. This 'rationing' also leads to increased mortality and morbidity among the poor and uninsured.

The idea of weighing public policy against cost is not new. Author points out that the US does it in public safety frequently: where the costs to implement some new safety measure would be too expensive for the lives it would save. In order to extend the issue to public health, there needs to be a standard measurement that money buys: author talks about the QALY, or Quality Adjusted Life Year. To reflect the difference between treating a 20-yr old vs an 85-yr old, this measurement uses life expectancy to assign more value to the young. The QALY approach runs into prejudicial or adverse discriminatory issues when it tries to deal with more fine-grained issues, e.g. deafness, quadriplegia, etc. The issue here is that disabled people may not want to be treated as second-class compared to healthy ones. Healthy people might claim that they would rather live shorter lives than be quadriplegic, but this might just be an inherent healthy-person bias. Author points out the double-standard here-- if it is just fine to be disabled (according to the disabled group) then why bother curing it?

The remainder of the article discusses the options that the US has in making a public option and that it can take many forms than the supposedly-reviled Canadian and British system.