New York Times Ed. misleads on health care rationing
In a piece written by Princeton professor, Peter Singer, for the July 15 edition of the New York Times Magazine, Mr. Singer makes the case that health care rationing is not only necessary – it is desirable.
While Mr. Singer may or may not be right, the problem with his argument is in the assumptions.
Here is how Singer sets up his defense of rationing:
You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?
If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.
VIA THE NEW YORK TIMES
On its face, we can easily see the point Prof. Singer is making. What is the cash value of an extra six months of life when that life belongs to a stranger?
The problem is, Singer’s argument takes the six month life extension as a constant when, if fact, it is not.
The prolonging of life data on Sutent (the drug used in Singer’s example), along with many other life-prolonging drugs, is expressed as an average. That means that approximately half the people who are given the medicine will have their life prolonged for a period less than six months while half will get to live longer than six months.
In speaking with a well-known and highly regarded oncologist, I discovered just how misleading Singer’s assumptions prove to be. The doc explained that while he has had patients who lasted only a very short time once they begin a regimen of Sutent, he has other patients who have lasted five years and are still going. Further, while some of his patients have experienced a reduction in the size of their tumor while taking the drug, thus extending life, others continued to experience growth in their tumors while still others found that their tumors neither advanced nor receded. He added this is often the case with a number of the new – and expensive- drugs used to extend life. For those who experience a tumor reduction or “freeze” where the tumor neither advances nor recedes, there is a decent chance life will be prolonged well beyond the six months. For those who do not experience a positive reaction, the result will be very different. But we never know who is going to benefit and who will not. I suppose we could call it a cancer lottery.
Does the fact that some people could extend their life by a very significant period of time alter how one might think about this question? I can see how it might be asking a lot of society to foot a large bill so that I might get an extra six months. But if we are talking about extending your life or my life for a significantly longer period of time, I begin to move to the other side of the question.
I should, at this point, note that the oncologist with whom I consult on these matters desires that I not disclose his identity. He is a well-known physician in cancer medical circles who prefers not to get caught up in the politics of it all. Thus, I hope you will forgive my failure to disclose his name as I make reference to him.
The doctor also made another very interesting point. How long do we think the pharmaceutical companies will continue seeking out and investing in life prolonging, or even curative drugs if the government prohibits the use of such treatments because of their costs? What would be the point of spending all that research and development money if the drug will not be available to all but the wealthy as a result of rationing limitations?
With all due respect, I believe that Professor Singer’s construct is, therefore, false and more than a bit misleading. If we are to analyze the value of rationing, one cannot simply take an average time period for prolonging life versus the cost of doing so as the basis for the equation. It simply does not tell the full story.
Indeed, you must factor in the fact that a percentage of people will gain far longer continuances of life. Would it not be more reasonable to first determine and then present that percentage for consideration so we can reach our conclusions based on what we know to be the opportunity for much greater success than the six month average? Should we not also consider that were the United States to follow the course set by the British system (which Singer correctly tells us has not approved Sutent because of the cost to benefit ratio), drug companies are likely to cease creating and delivering life- prolonging drugs? Is that a price we are willing to pay?
You might also want to consider this- according to the oncologist whom I spoke with, when you break out the cost of all the meds being given to cancer patients in America in the effort to prolong their life, it works out to be about $25.00 a year for each American. As you make your assessment as to whether or not rationing of these medicines is appropriate, you might want to ask yourself if it is worth $25 a year (like buying $25 worth of lottery tickets) to know that, should you or someone in your family become a victim of cancer at some point in your life, you will not be told that life prolonging drugs are not available because the country cannot afford it.
There is much more to this question than what is presented in the Times’ piece. Americans may ultimately need to face the question of health rationing. Let’s just be sure that as much information and honest perspective is available to everyone so that the most reasonable conclusions can be reached.
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Very interesting and another canard from the opposition.
What is not said is why the drug is so expensive here. Had we the power to negotiate prices maybe the price can come down and we wouldn’t need to do a cost/benefit analysis in the first place, an obscene thought to begin with.
It should be noted that in Great Britain, where they have that socialized Health Services, the price of Sutent for six months is 14,400 pounds and even with our lousy dollar exchange that converts to $23,517.88. Half of what it is here.
libtree-
I don’t entirely agree with you on this one.
1. Cancer drugs are, by their nature, expensive. The market for them is not what we might consider a ‘mass” market (thank goodness) yet the costs of development and production are extremely high.
2. While the cost of Sutent might be 50% less in the UK, what good is it if the government does not permit use of the drug? And they do not. That simply means that those with the money to buy the drug on their own can get it 50% cheaper than were they to buy it in the USA. However, even that is not an accurate assessment. While Great Britian does allow an individual to elect to purchase a non-approved drug, such as Sutent, on their own, by so doing they give up all the right to government payment for ALL treatment surrounding the particular illness. Thus, a Brit who is being treated for kidney cancer and who elects to spend their own money for Sutent could do so, but would no longer be entitled to government payment for hospital stays involved in their kidney cancer, physician costs, dialysis, other meds, etc. To be clear, they don’t give up their right to government care for other illnesses, but by electing to purchase a drug not authorized by NICE, they do waive all government treatment rights with respect to that drug. So are they really saving 50%?
I don’t see this as a canard at all. And before you are too harsh on the drug companies (who are entitled to some scorn but, in my opinion, that scorn is often overdone), think about how you might feel about them should you ever NEED these drugs. If you lower the profit potential to the drug company, (and the US is now pretty much the only place where they can score big profits as all other industrialized nations have government imposed price controls in order to keep costs down), then they will have little incentive to pursue these important drugs. How is that likely to make you feel should you or someone you care about need one of those drugs someday?
By the way, I’m curious where you were able to locate these cost numbers for Sutent in Great Britain????
In response to another comment. See in context »Rick,
Do you think pubic opinion would change the way an HMO or other health insurance company change the way they do business? Keep this in mind and we will get to the canard. Let’s address your rather long response…and thank you for that.
1) Yes, cancer drugs are expensive and pharmaceutic companies spend a great deal on research and lots of that research is funded with our money.
However there is an upside and downside to this research. Studies done with Pharmaceutic money alone tend to be published less, maybe to protect patents, but peer review seems limited and that does not serve the public.
Now the profit incentive is a great motivator but it has also led to abuse. For example generic drug companies often delay releasing a cheaper version of a drug because Big Pharma companies often simply mix another drug into the formula to obtain a new patent. Thus keeping the price artificially high to us poor people.
Secondly when profit is the driving motive rare deceases get little to no research. The Sutent research is interesting because the early announcements of the research claimed it could be effective for a wide variety of tumors and Pfizer’s stock jumped. When the results proved a narrowing of effectiveness Pfizer worried and printed “don’t worry articles” leading a cynic to conclude that maybe they wouldn’t have…I stray from cynicism. The point being that research is focused on magic bullet, the most profitable route that leads to over hype and drugs that are no more effective than generics.
Third is the marketing of drugs, where they really spend the money. Lets put aside the doctor incentives.
More destructive is this: some drug has a side effect that say could help something like…Restless Leg Syndrome or RLS. So doctors push the drugs that work on dopamine, like depression drugs that have been out there for some time and wham o thank you ma’am, we have a new syndrome that can actually be cured by getting off one’s ass and stretching. Or a blood pressure medicine has the effect of making people sleepy…great new anti-anxiety drug…that just happens to fuck your liver.
And fourth you know about abuse and its incursions into the FDA.
2) I believe National Health in Britain and it’s is not one approval process, there are several like Ireland and Wales…but I think they all approved the drug Sutent in March 2009 after their testing agency NICE(?) speeded up the testing process. Six week trial will cost 3,000 pounds. It is only permitted for use in advanced Kidney cancer at first and in May for gastrological advanced stromal tumor (GIST).
3) It is a carnard because Obama is suggesting that a panel of doctors be the one’s to decide this “rationing” instead of insurance agents.
But let’s get back to Sutent because I believe you are correct NH in England did reject the drug as first line treatment until public pressure forced them to change course.
That is the difference, public figures who piss off their citizens, who do stupid or destructive things can get thrown out on their ass. It is very rare to see those in the corporate world who fuck things up ever get replaced much less thrown out on their ass. That’s the carnard…this country went into fits over pulling the plug on a brain dead woman imagine cutting drugs that could prolong life. Something the insurance companies already do.
Lastly I do need Big Pharma, my mornings include a breakfast of colorful pills. I love new research, hope for the best but these guys, insurance companies and Pharma’s excessive prices for drugs that have been “reformulated” have brought me to my knees.
Where did I get the price info…I will tell no muggle.
In response to another comment. See in context »libtree09-
One thing you must tell us is who you are! You are one very smart man or woman.
I will only quarrel with one thing you said. “It is a carnard because Obama is suggesting that a panel of doctors be the one’s to decide this “rationing” instead of insurance agents.
It is possible you may turn out to be correct about what Obama is proposing – but, as it stands right now, the proposed independent panel would be advisory, intended to collect data on what does and does not work, the same to be passed along to physicians who can use it or not to improve patient outcomes.
As for the rest of your comments, while I’m not entirely sure that they all speak directly to the issue at hand, you are right in every thing you are saying. If I didn’t know better, I would have thought you read the chapter on Big Pharma in my book, particularly the part on copycat drugs and other “tricks’ intended to accomplish new patents with what are, essentially, old drugs. The good news on this front is that the patent office has been clamping down. With some of the more profitable patents expiring this year or next, we are seeing less copycat efforts and more money being spent by Big Pharma purchasing smaller, promising biotech companies. This is a good thing.
To the extent you are comfortable telling all of us, it would be interesting to know about your background. You really are one of the more impressive commenters when it comes to knowing what you are talking about.
In response to another comment. See in context »Rick here’s the problem I have with both you and Mr. Singer and anyone else for that matter who decides to bring up the rationing argument. Health care already is rationed, over 40 millions American are already priced out of the system. People are routinely denied treatments by insurance companies, and usually our drug choices, what doctors we see and what hospitals we go to are dictated by what and what not the insurance company will pay for. Also every insurance plan I know of except Medicaid and Medicare come with a lifetime benefit cap.
This entire rationing argument is nothing more than right wing bullshit and should be treated as such.
Well, all that you say is true- except that it is not what the discussion is about. I suppose you could choose to take all your points and call it rationing, but that would certainly be outside of the definition as it is typically understood.
Prof. Singer’s approach, if adopted, would absolutely put a limit on what is available under Medicare and Medicaid-while, as you point out, none currently exists. If a drug is no longer permitted because the cost outweighs the benefit (as determined by whatever governmental body would be establishing to create such guidelines under a rationing sysem) then such a decision would apply to Medicare as much as it would apply to a private insurance company.
So what is it you are saying?
Further, being “priced out” of the system is not rationing unless you consider a home that costs 20 million dollars as being “rationed” because most people can’t afford to buy it… or a car that sells for $250,000 being rationed because most folks are priced out of buying that car. Essentially, your definition of rationing is the definition of capitalism. I suppose you could say that – but I doubt you are going to get much traction for your argument that we already have health care rationing because 40 million people are priced out of the insurance market.
Before you go getting all crazy, I’m not defending, supporting or in any way condoning 40 million people being priced out of health insurance. I’m just saying that if you stop and think about it, you will probably come to a more logical conclusion.
Further confusing is that my post clearly takes issue with Prof. Singer;s conclusions and methodology, yet you still seem to have a problem with both me and Prof. Singer bringing up rationing health care – no matter which side of the fence they sit on. So, here’s the deal – because I’m not much of a believer in the idea of health care rationing, I’ll do my best to warn you ahead of time when I am going to post on the subject or use the word “rationing”. That way you won’t have to be upset by reading a post on the subject.
In response to another comment. See in context »My point being is that rationing is in the eye of the beholder. Rationing has always existed where medicine is concerned in one form or another. Also I’m not some hysteric who’s needs to be told not to go all crazy or warned ahead of time when you’re going to discuss rationing. My other point is that the rationing argument is bullshit and should be treated as nothing else but bullshit.
Is there evidence at all that rationing is going to be the issue that the right wants to make it out to be? Why not counter the argument with the fact that public run health plans typically cost less to run and therefore we will be able to provide these expensive life sustaining treatments to more people who are currently receiving them? Your anonymous oncologist what are his feelings about a public option? Why should we be buying into his fear mongering on the issue of future drug research without knowing the entirety of his feeling on the issue in general? Frankly I see this piece as giving ammunition to the fear mongering not presenting a reasoned argument as to why it’s a false argument.
In response to another comment. See in context »As I say, next time I write on the topic I’ll give you a warning..
As for feeding the right wing, fear mongering, whatever, see Tom Daschle’s book on health care reform and the role rationing could have played in his left wing, pie in the sky, fear mongering plan.
Yes, the opponents of health care use the concept of rationing as part of their “fear mongering” campaign. But that does not change the fact that serious health economists (including left leaning economists believe that rationing may be a part of our future, just as it has become a part of the present in EVERY OTHER INDUSTRIALIZED COUNTY ON EARTH…and…opps… most of the are left leaning.
The fact that a party uses a club in the wrong way does not make the issue any less real.
In response to another comment. See in context »FYI:
Obama Campaign Arm Doubles Down, Targets House Dems On Health Care
(http://www.huffingtonpost.com/2009/07/18/obama-campaign-arm-double_n_239258.html)
I read it but what confuses me is that articles like this seem to give you confidence in the ultimate outcome where it does just the opposite for me. The fact that Obama has to double-down on House Dems. reveals the problems he faces in getting this done. It surely doesn’t reveal that this is a done deal.
In response to another comment. See in context »I posted a link, I didn’t offer an opinion on the link. I never thought for a moment that the president wouldn’t have to “double down” with some of the blue dogs. You’ve repeatedly said people need to be letting their members of congress how they feel on the issue. The president at a very timely moment in the process is rallying the troops, something he is extremely good at. How is that not a cause for optimism. And Rick why does my optimism for a very positive outcome on the issue seem to get your dander up so? Sorry if I don’t feel compelled to turn into Henny Penny every time we hit a bump in the road, I’d much rather keep my head down and push forward.
In response to another comment. See in context »My dander gets up because I know too many like you who actually believe this battle is, for all intensive purposes, over. While you and I, for the most part, share a similar view of how we would like this to turn out, the expectation that it is anywhere close to being a done deal is just wrong and could help lead this to defeat.
What is happening is anything but a ‘bump in the road”. If you know the history of health care reform – or lack thereof- in the United States, you would know that where we find ourselves is extremely similar to where we have found ourselves so many times in the past. Since 1921, only one American president has succeeded in reforming the health care system and that was Lyndon Johnson. Teddy Roosevelt couldn’t do it. Franklin Roosevelt couldn’t do it. Only Johnson could. I am very pleased that Obama is our president, a feeling shared by 58% of my countrymen. But even Obama knows he doesn’t have the pictures and the history Johnson possessed when it came to forcing legislators to do his bidding.
I too am optimistic that something good might happen. But I’m not letting up and I don’t think anyone else should be letting up. I recognize that I have never succeeded in bringing you to an understanding that this is much harder than you realize and the odds will be against it right up to the moment something passes. So, if I’m being Henny Penny, so be it. I’d rather be that, and keep pressing, than finding myself severely disappointed when whatever reform we might get fails to become reality.
I am going to continue to pressure people to stay involved and push for this. When this is all done, I want you to be saying to me, “See..I told you it was a done deal.” rather than me saying to you, “I toldyou so.”
In response to another comment. See in context »I’m with Brian on this one, that the current system already rations care. I’ve blogged here twice on this issue; as someone who spent 30 years using the Canadian healthcare system, which de facto rations some forms of care and treatment, I’ve seen that collective compassion — embodied by universal healthcare — allows an entire society to thrive in ways Americans can only begin to fantasize about. The current “debate” is a big game of whack-a-mole — every time we see a potential solution, someone shoots it right back down. Every solution will require change. Change seems to terrify people.
Caitlin
You’ve kind of lost me here. While there is much I also like about the Canadian system, one of the features I’m not particularly thrilled with is the rationing.
Are you saying it is “collective compassion” to tell a mother that a drug which might extend her child’s life six, twelve, fifty months is not going to be available because, on a cost/benefit ratio, the drug doesn’t measure up? I’m having a very difficult time seeing the compassion in that, collective or otherwise.
While I greatly support our health care reform efforts, in probably the same or similar manner as you, that doesn’t make the issue of rationing any less real as something which we will be forced to examine and contemplate. My post was to point out that Dr. Singer’s argument was based on a faulty premise — not to make a political statement about the pros and cons of health care rationing.
I will say to you what I said to Brian- while it is true that the opponents of health care use the concept of rationing as a tool to frighten people, this doesn’t mean that this issue will not be on the table and something we not be thinking about and discussing. One of the great champions of health care reform, Tom Daschle, certainly doesn’t see it as a big game of “whak-a-mole”. In fact, he feels it may become necessary, to some degree, if we are to sustain a viable health care system.
You don’t make something go away by simply saying, “Oh..the other side is trying to terrify me with this issue. I hate the other side. Ergo, there must be nothing to the issue.”
Rationing is and will continue to be a more substantive issue before the American people whether we succeed with health care reform or not. I don’t quite get the benefits of burying our collective heads in the sand.
In response to another comment. See in context »Rick their rationing argument is bogus, there is no data to back up their premise. They’ve done a very good job at finding that one person who’s fallen through the cracks and presenting that as an example of the medical horrors that will rain down on the American people should we reform health care. We have 10s of millions of people who are falling through the cracks. It’s not the fact that you’ve brought up the issue, it’s your response to the issue that I find enraging.
In response to another comment. See in context »1. Who is the they you refer to?
In response to another comment. See in context »2. What are the cracks you are referring to that the person they found has fallen thru?
3.There is absolutely nothing in my post that would indicate I support the political argument usng rationing that you keep defaulting to.
4. Can you tell exactly what it is in my post that you find “enraging”?
IF you recall, your initial comment was that I brought the discussion up in the first place. What exactly is in the post that enrages you?
“They” are the right. When referring to someone falling through the cracks I’m thinking of an ad being run right now about some woman who had a brain tumor in Canada and came to the US to be treated.
I find the comments by your anon. oncologist enraging. I think it’s fear mongering and you present his remarks as some expert in the field of drug research financing. For all I know he could have lots of drugco stocks in his portfolio. For the past 20 years I’ve worked closely both personally and professionally with many MDs. I learned long ago that though they speak as if they are delivering the sermon from on high there is no reason at all for me to buy into what they say, especially where this issue is concerned.
And no I did not find fault with you bringing up the issue, I find fault with you for giving what is in my opinion not a creditable argument creditability. The entire premise of your piece is that rationing is inevitable and we had better deal with it. I take exception to that. I don’t see any evidence of that, and you have presented nothing to prove me wrong expect for the speculation of some self appointed experts on the issue.
In response to another comment. See in context »I agree, of course, that rationing has to be discussed.
But this is a country there individual needs are always deemed paramount, no matter what it costs financially or what it costs someone else who won’t get X because, at least, you and your family got Y. What we do not have in this “debate” is transparency! Drug company CEO’s saber-rattle that we won’t get access to new wonder drugs — but voters or legislators don’t really know how much of this is truth. Doctors fear losing income, even if they already make millions. Patients fear the bogeyman of some government bureaucrat — not your own doc — making decisions about your care.
Millions fear losing….something….when right now there is no guarantee the very best and most comprehensive health plan is not — to keep profits high — *already* severely rationing what we get. They do! I’ve experienced it myself, twice. Not with lifesaving drugs but with access to physical therapy and other necessary care. The HMO simply cut me off, my needs, backed my by severely frustrated physicians’ repeated demands for service, be damned. That’s rationing!
And I have never, personally — or through anyone I know in Canada — experienced rationing there. Of course, it happens. I have not seen it, and I have watched many relatives and friends go through six-hour neurosurgery, treatment/hospice care for terminal cancer, successful care for cancer, etc.
Ok, this I can relate to..
In response to another comment. See in context »You make some very good points. I do agree that it is “rationing” when your HMO cuts you off when the doctor thinks you need to keep going. But, with respect to your first paragraph, there are some of these things that we do know, some via empirical evidence and some by common sense.
For starters, I don’t think anyone is yet debating rationing. While conservatives like to bring it up to scare people (as you and Brian noted), there has yet to be a debate because it is not yet an issue that is really on the table. I do, however, think we will reach a day where the debate does become necessary.
This is a country where individual needs are deemed paramount. It is built into the system. But is it a bad thing? Should it be, as Spock would say, the needs of the many outweigh the needs of the few? Or should our vigilance toward individual rights be front and center.
That is really an entirely different conversation but I agree that it is at the heart of any discussion regarding rationing of health care.
On the drug thing — it really does take a drug company CEO to tell us that if the government is going to bar a particular drug on a cost/benefit basis, that they won’t be able to manufacture that drug. It is simply common sense. As for why the drugs have to be so expensive, again, pretty simple economics. Thankfully, some of these drugs- cancer, for example – have a fairly limited market. Using the example first used in the original post, Sutent is for kidney cancer patients, a fairly limited market. Do you really think that makers of that drug could continue to produce it if government says that it won’t pay for it. Removing all Medicare patients would, effectively, kill the majority of what is already a small market. Now, if it is you who needs Sutent, I’ll feel badly that you cannot get it. If it is me or my famil.y that needs Sutent, I’ll be apoplectic. That takes up back to the needs of the many versus the few. The simple truth is that we tend to appreciate the importance of the needs of the many until the few in need includes ourselves.
As for your final paragraph, I’m afraid there is a fairly large amount of expensive drug rationing in Canada. This would not show up in neurosurgery nor would it show up in hospice care (If they were being treated with a drug to extend life, they probably would not be in hospice care until the drug has failed). I’m not “cracking” on the Canadian system. As I said earlier, there is much to like about it. Sadly, every health system in the world’s industrial counties have their pluses and minuses. Nothing is perfect.
Rick the bottom line, for all of the so called “rationing” that takes place in the Canadian and British system the people of those countries live longer and their infant mortality rates are better than ours.
Life expectancy in Canada is 80.34 years, in Great Britain it’s 78.7 years, in the US it’s 78.06. Infant mortality rates for the same three countries:
US 6.3 per 1000 births
Canada 4.8
Great Britain 4.8
According to a 2007 Harvard study 49.6 of all bankruptcies in the US were due to health care costs. I suspect the rate in the UK and Canada is 0!
VIVA RATIONING!
Brian – So, I guess you’ll be fine with it when the drug you need someday to give you another year or two of life will be unavailable to you? If so, that is certainly your right.
In response to another comment. See in context »With respect to your other comment, it is also your right to not accept the perspective of the oncologist with whom I consulted. This is particularly true given my inability to reveal his name as the source of my comments. However, I don’t really think your knowing his name would alter your opinion.
Where I do take issue is with your understanding of the drug industry. Yes, there have been some drug innovations in France and quite a few lately in Israel. However, ask any Israeli pharmaceutical company and they will tell you that they only succeed if they can succeed in the US market. I speak with many of them often and I can assure you this is the case. Indeed, so strong is this belief that the Israeli’s are finally now getting to the point where they are forming their own distribution in the USA as, up until now, they’ve been reliant upon receiving small royalties for their discoveries from the major pharmaceutical companies who distribute for them in the US. While anyone is entitled to their point of view, it is simply wrong to believe that a pharmaceutical company can be particularly successful without the US market. This is particularly true with the highly specialized drugs which treat a limited market – such as cancer drugs.
Rick a great part of my problem with this entire “rationing” argument is I just see it as emotional and not very rational. It ignores several very important points. Most important of which is we already are spending more money both in terms in per capita spending and percent of GNP. It ignore the fact that we already are spending the money, but in this country a far too high percentage of what we spend ends up going to areas that have nothing to do with delivery quality care to all.
I find it amazingly immoral that we are subjected to arguments about another aspect of health care costs when the people who are most likely to invoke the rationing argument sat silent for decades as the American people were being sucked dry by the all mighty market.
“US. While anyone is entitled to their point of view, it is simply wrong to believe that a pharmaceutical company can be particularly successful without the US market.”
Seriously Rick you don’t see something wrong with this statement? You’re ok with the America consumer of health care baring this burden for the entire world?
In response to another comment. See in context »Brian, what I really think about this is that it is unfair-but necessary if the world is going to get the benefit of life saving drugs. Of course you are right that it is not fair that we have to pay more than anyone else. Our government should have acted a long time ago to put us on a par with – or get ahead of – the rest of the world. But here we are. As someone who is, without question, alive today because I was able to get certain life saving drugs, its very hard for me to root against the makers of these drugs. Would I like everyone to be able to pay less? Yes. Am I willing to pay more than another American because maybe I can better afford it? Yes again. There is no question that I am in the group of people who will end up getting the shorter end of the stick in health care reform. I’m too young for Medicare and my earnings are such that I will clearly be in the surtax situation as the plans are currently crafted. What’s more, because I am older, I will pay a higher premium cost than the younger people who will have to buy insurance under an individually mandated health insurance program. I’m okay with all of this. I don’t love it – but I can accept that I should probably pay more than others if it means that more people will have access to health coverage.
In response to another comment. See in context »But I’m also a realist. I don’t see an up-side of putting my own life in jeopardy in order to teach the drug companies a lesson. I also don’t want to put other lives in jeopardy by arguing for teaching the drug companies a lesson. Let’s say we do crack down on these companies, begin rationing what may or may not be available, limit what they are paid, etc. Let’s say that it does cause them to greatly reduce their research and development activities. Maybe someone will benefit a few generations down the road – but maybe I’ll be dead because a drug that could have saved me never got developed. I’m just not that good of a person!
“but maybe I’ll be dead because a drug that could have saved me never got developed. ”
But Rick, we already live with that, that’s my point all along. There is rationing created by the fact we have a market driven system of medical research and health care. Who knows, pancreatic or anal cancer might not be the death sentences they are now if they were a larger (and therefore more profitable) patient population. I’d rather err on the side that gets more people into the system not fewer. That’s a price that’s more in line with my own values.
In response to another comment. See in context »“But that does not change the fact that serious health economists (including left leaning economists believe that rationing may be a part of our future, just as it has become a part of the present in EVERY OTHER INDUSTRIALIZED COUNTY ON EARTH…and…opps… most of the are left leaning.”
And when and if this becomes an issue this is a discussion we voters can have with our elected officials in the public forum. Not the corporate board room as these issues are now decided. How refreshing, health care answerable to the voters, not the stock holders.
Rick what about all those expensive drugs that were invented outside of the US? Israel has national health, interferon for example (a very expensive drug) was developed there. What about the slew of drugs developed at the Instistut Pasteur?
The heart of the matter, I think, is the needs of the individual versus those of the collective. The latter is made up of the former, no? Talk of rationing is all abstract chatter until — suddenly — it’s you or your Mom or child need something they can’t have. But why must individual needs predominate because it’s “built into the system”? So was slavery, for a while, because it was immensely profitable for a few, while deeply injuring many more.
Canada brought in its healthcare system in the 1960s, so others have grappled with, and somehow resolved, these difficult issues before. And, true, no system anywhere is perfect.
Again, Caitlin, you make good points.
In response to another comment. See in context »However, while these other systems have grappled with it, they too have trouble resolving them. In England right now, there is a large outcry about the government prohibiting use of a particular cancer drug which has had very good results in other countries. It is, unfortunately very expensive. The problem in the UK is that they will let you go get the drug on your own but you then must cover all the costs involved in your illness- hospital, docs, etc. You basically forfeit your right to government provided care – for that illness only – by going outside the system to get the drug.
The British government is coming to the conclusion that this might not be the right way to go and the topic is under very active consideration by NICE.
My point is that these issues will always be vexing and all nations struggle to find their way to right answers.
What troubles me is when people from both sides of the political equation turn it into a competition. This is not about our way is better than their way or vice versa. All of these systems have had strengths and weaknesses, certainly including the American system. There is much we can learn from the health care systems of other countries – both good and bad. If we were smart, we would adopt as much of the good as we can and avoid the bad. The funny part is everyone is always supporting or shooting at the Canadian and British system when one of the finest operating health care systems on the planet is the Australian system. And what have they done? Taken the best of the British system and the best of the American system and found ways to integrate the two to come up with a pretty good approach. Yes, they too are having cost control problems, but its a pretty intelligent approach.
As to rationing, this is a subject that will find its way to the public agenda. It has in every country in the world and it will here.
Who can argue with an appeal that “information and honest perspective” be used for reasonable discussion. But it seems to me that even if a deeper understanding of medical statistics renders Singer’s example meaningless (or even misleading), the fact is we have many, many more treatment options–from the proven to the likely-to-work all the way to a Hail Mary pass–than we can collectively afford. Too much technology, not enough money. Someone will have to do without something.
The question of rationing is how to choose who gets what. Rationing is doling out limited supplies based on some sort of rationale. Our current model is not one of rationing, even though HMOs daily deny care. Ours is a competitive model, healthcare is provided, and denied, based on “economic health.” We now know our competition model doesn’t work. And rationing scares people? So what else is there, maybe treatment lotteries? Or maybe we’ll be able to see that rational rationing may be the best we can do.
“Or maybe we’ll be able to see that rational rationing may be the best we can do.”
Wish I had said that!
In response to another comment. See in context »Todd-
In response to another comment. See in context »Don’t think I’ve seen you as a commenter before but I’m very pleased you came by. I don’t know that I agree with you in the entirety, but your arguments make a great deal of sense and your logic is quite sound.
I do hope you will return more often as I love reading this type of comment.
The area of discussion, when it comes to the healthcare bill, that I don’t see much of, is the ethical questions. How much is a life worth? Do we want to be making that decision? Why do we assume, and make decisions based on the idea that it is someone else who has the problem? I can answer that one, actually. The decision-makers already have full healthcare provided for them, and probably better that the government will provide. The considerations that those who don’t need what they are considering are going to come to different conclusions.
I must admit, the medicalese is really confusing.
Libtree. I think I got the hidden meaning to your name. Thomas Jefferson’s quote about “the tree of liberty, which must from time to time…” Not sure if that is right, but it makes sense to me.
iskidtostop-
In response to another comment. See in context »The ethical question you raise is at the very heart of the rationing question. And you’ve got it right – its very easy to take an objective, overview when it isn’t you but a stranger who has the problem. The thing is, some day we are all going to be that stranger. If people could understand this fact of life, the rationing question takes on an entirely different perspective.
That’s the same question I’ve been asking myself; what if I was the one with cancer? Today, my insurance would cover me without a large financial burden and provide some services not available in other universal care systems. I would get immediate surgical care that could save me or reduce my pain and probably the best cancer treatment in the world. But at what cost to others? I’m not burdening others as my insurance premium was assessing my personal risk with a pool of insured people. What about those not insured? One could say that their coverage is already included in the hospital costs, but not at the level of service I would get.
But then I see myself in universal care with the same cancer. Will I get the same level of care? Will it cost me more not only to get non-covered services but with progressive universal costs? I will probably have to wait longer for surgery in lines with others. How much more pain will I suffer. There is NO other option to get immediate care if it is not urgent. If there were say 10 others discovered on same day and same urgency, who will be first. The person making $20K a year or the person that makes $100K a year? What if the person is an alcoholic, a drug addict, or criminal. But, this is where it gets very messy and almost impossible to make a fair decision. Even worse, should the government make those decisions? It would punish those that are more productive in society.
The rationing comes down to two options. Ration by money/social productivity or ration my government lines. In general ration by money is rationing by those more productive in society just as everything in our life is. Rationing by lines, places everyone in a line. A line controlled by the government.
Neither seem quite right to me. Ration by money is closer to the right path, but not quite there. Lines allow anyone, no matter how much I would feel that person does not deserve the same care. Neither really seem to be ethical or fair.
In response to another comment. See in context »All the right questions. From my point of view, neither option is “right”. You should take a look at the Australian system of health care. Coverage for everyone but significant government incentives offered to everyone to switch over to a private health care plan.
In response to another comment. See in context »iskid- by the way, what type of biking are you into? I’m a long time road biker. Since you live in Northern Cal. (I’m in Southern Cal) you could be hitting the mountains or the roads.
In response to another comment. See in context »