
Why We Must Ration Health Care - robg
http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?ref=magazine&pagewanted=all
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mynameishere
If we're going to be making up numbers like "How much is a human life worth?"
perhaps we should first make up some less dangerous numbers like, "How much is
a tiny little pill worth?" It isn't the free market that came up with "54,000"
dollars--and if the government is gracing a company with patent enforcement
(really, a price floor), it may as well grace it with a price ceiling as well.

~~~
potatolicious
I commented on this on another forum as well. I'm a Canadian living in the
USA, and the health care costs here are astounding.

As far as I am aware, we do not ration health care in Canada - if it is
available and justified, we use it. Why? Because unlike the United States, the
Canadian government doesn't pay $54,000 for a few pills. Yes, it's true, our
public health system pays _far less_ (sometimes over 70% less) for the _exact_
same drugs from the _exact_ same drug companies.

The problem here is that there is no bargaining power in private health care.
The providers don't really care how much they pay for drugs, because any cost
is simply passed onto you, the consumer. As consumers you have very little
recourse except to take it. A large, centralized health care system has the
bargaining power _and_ the incentive to push drug companies for lower and
lower rates.

Having now seen how much Americans pay for health care, and how little they
get for their money, I have a hard time imagining why people continue to
support private health care at all.

~~~
mynameishere
_how little they get for their money_

I fear that one of the things we get is to subsidize the world with respect to
drug innovation. Pfizer, _et al_ , put up the money to develop drugs knowing
that they can gouge unwilling customers in the USA (all health care buyers are
unwilling--that's why health care isn't a free market).

If the US starts putting ceilings in, the one big side-effect may be a
reduction in research.

~~~
DarkShikari
The drug companies spend vastly more money on marketing than they do on
research, and furthermore, the vast majority of the research goes into
treatments rather than cures, because the former makes money and the latter
does not.

The world would be better off without American drug companies dominating the
market, even if it meant no Viagra.

~~~
evgen
Strange that you managed to skip the real cost sink for new drugs and medical
procedures: testing. The marketing cost is a direct result of the huge cost of
getting a basic research breakthrough moved all the way through the process to
a safe and effective treatment that has FDA approval.

> the vast majority of the research goes into treatments rather than cures,
> because the former makes money and the latter does not.

[citation needed]

This sort of conspiracy-theory bullshit is really annoying because it fails
even the most basic logical analysis. If company A develops a treatment for a
disease then it will be able to make more over the long-term than company B
which develops a cure for a disease. But if company A develops a treatment and
two years after it gets through testing company B comes up with a cure for
that same disease then company A is going to lose a boatload of money. The
only way this would work is if these companies were acting as a colluding
cartel, and so far all evidence seems to indicate that the companies hate each
other even more than we hate them.

> The world would be better off without American drug companies dominating the
> market, even if it meant no Viagra.

I happily invite you to try to live the remainder of your life eschewing
treatments developed by American drug companies. Viagra may make a nice
whipping-boy for your tirades, but you do know that it was developed when
stage 2 testing for an angina drug revealed its more popular side-effect,
right? Pfizer did not set out to keep aging baby-boomers smiling, it just
happened upon it while actually trying to cure coronary artery disease.

~~~
DarkShikari
_This sort of conspiracy-theory bullshit is really annoying because it fails
even the most basic logical analysis. If company A develops a treatment for a
disease then it will be able to make more over the long-term than company B
which develops a cure for a disease. But if company A develops a treatment and
two years after it gets through testing company B comes up with a cure for
that same disease then company A is going to lose a boatload of money. The
only way this would work is if these companies were acting as a colluding
cartel, and so far all evidence seems to indicate that the companies hate each
other even more than we hate them._

It doesn't require a "conspiracy theory"; it's simple obvious fact: drug
companies don't fund studies to develop and test drugs that won't be
profitable. Tell me, why do you think they would pay hundreds of millions of
dollars to develop and test a drug that won't make money? Your argument
doesn't even make any sense; it _requires_ that drug companies do something
that is financially illogical.

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tc
I don't want to start a deep thread on this, but I do want to point out that
one of the advantages of a free market is that you only have to make these
choices for _yourself_ , not for others.

You can select an insurance policy with rationing and a $10M lifetime benefit,
and I can select an insurance policy without rationing but with a flat $1M
lifetime benefit. The system we have now is not free because governments
dictate what kind of policies medical insurers can offer, preventing consumers
from making many of these types of choices.

When we decide that one size fits all, then the only choice is to have
politicians and bureaucrats making these decisions for everyone.

When you make a decision about what your life is worth, that seems morally
sane. When someone else makes a decision about how much your life is worth,
that seems morally objectionable. Only free markets allow us to mostly avoid
the latter choice.

~~~
Raphael
If the national health plan is inadequate for the rich, a private system will
continue to cater to them. The point of the national plan is to raise the
floor.

~~~
tc
Socializing healthcare drives up costs for everyone, pushing higher quality
alternatives out of range for more people. Providers no longer compete on
price, and consumers no longer factor price when selecting providers or
moderating their use of resources. Combined, these factors will make (and
already have been making) private alternatives unrealistic for all but the
most wealthy, whereas prior to the government takeover of healthcare, high-
quality private care was well within reach for (at least) the lower-middle
class.

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sh1mmer
I found this article really interesting but the author didn't talk about
promoting wellness which seems to be a very taboo topic in the U.S.

I'm vegan (which reduces heart disease and cancer risks), I don't smoke and I
exercise moderately. However the pool of risk into which I am assigned also
includes people that eat large amounts of cholesterol, smoke and don't
exercise at all.

In this article the author explores the topic of ranking treatments by their
effectiveness in terms of QALYs, but a large amount of chronic and acute
illnesses can be avoided by improved diet and exercise. As such any system of
reform should look at a large piece of education and social change to
encourage this.

~~~
jswinghammer
It's true that you are right now subsidizing others health care and someone
else will subsidize you when you're sick from something you didn't expect to
get.

~~~
sh1mmer
It's not about me subsidizing others, I understand how insurance works it's
about disproportionate risk. There isn't an emphasis on creating change in
society to encourage people to live lifestyles that needlessly expose them to
risk, and burden our health system.

It's unacceptable to not give people treatment for acute problems. However no-
one is talking about how a lot of those acute problems are made much more
likely by some lifestyles than others.

If you buy car insurance you pay more or less based on your risk factors such
as age, experience, points on your license, etc. If people choose to increase
their risk for health issues than it seems unreasonable that the rest of us
should have to pay for their lifestyle choices.

It also seems like any healthcare reform should attempt to encourage people to
reduce unnecessary burden on the system. That might make it more possible to
increase the amount available to spend treatments for people with terminal
illness, because less our of GDP would be spent on treating unnecessary
chronic or acute illnesses.

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swolchok
I was a bit surprised that the article took so long to mention that everyone
dies eventually. Lots of the rhetoric around this issue (e.g., "saving lives",
"sentencing him to death") ignores that everyone is born with a death
sentence.

(Sorry if this post makes you get all existential for a while. Seriously.)

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sh1mmer
This is a really interesting article.

The author(1) looks at the reasoning behind healthcare rationing and suggests
that it isn't as bad as it appears. Essentially he suggests that it's easy to
find media-friendly stories of how rationing healthcare screws some
hardworking soul, but that doesn't mean it isn't a good idea.

He look at how we already put a cost on life by limiting the budgets for
things like consumer product safety standards, and the amount spent by
transport agencies on safety. He argues there is an objective measure that
economists have been using for years (quality-adjusted life-year, or QALY) to
assess the cost-effectiveness of treatment and that the US government could
use this for effective healthcare reform.

He goes on to point out that while it's easy to point out the places in
universal health-care systems where people are excluded from treatment because
the system tells them it isn't available, it's much hard to find when people
self-deny treatment for fiscal reasons. He cites the case of a woman in the
U.S. without health insurance who didn't take her blood pressure medication
because she bought food for her family. As a results she died in the ER with a
brain hemorrhage.

He also compares the system in the U.S. to those of the UK, Canada and
Australia, and suggests that health-care reform in the U.S. would not have to
be modeled on those systems but could even be modernized to a system that
suited the American temperament better. The Australian system, for example,
provides universal healthcare, but also allows citizens to buy into private
healthcare schemes which do not restrict treatments.

This is just a poor summary and an extremely interesting article.

(1) Peter Singer is professor of bioethics at Princeton University. He is also
laureate professor at the University of Melbourne, in Australia. His most
recent book is “The Life You Can Save: Acting Now to End World Poverty.”

------
jpwagner
...Why we must reform the current system without involving the federal
government.

~~~
jrockway
We've already seen how that works; the money is given to the shareholders of
insurance companies rather than to the policyholders in need of medical care.

The government does not need to make a profit on healthcare, which is why
people are turning to them. (Plus, we've seen this system work in other
countries. The US will not be the first country to give everyone healthcare;
it will be one of the _last_.)

~~~
gojomo
Depends on how you define 'work'. Nationalized healthcare where tried has
delivered better results in some dimensions, worse in others. Those countries
often rely on medicines and procedures pioneered in the USA's more open
medical markets; if we give up that role, who will pick up the slack?

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windsurfer
Flagged for registration wall... even thought it's the nytimes. If someone
wanted to write a synopsis and write a commentary about this article, that
would be swell.

~~~
ryne
<http://www.bugmenot.com/view/nytimes.com>

