January 12, 2011

Why should the government decide who is more "worthy" of receiving care?

By Why should the government decide who is more "worthy" of receiving care?

Author:  Anne M. Hayes

"The decision is not whether or not we will ration care–the decision is whether we will ration with our eyes open."

This statement was made by Dr. Donald Berwick, the man President Obama appointed last year to head Medicare and Medicaid. And while it sparked a bit of outrage at the time, his point is perfectly valid. Really, the problem is not so much that he favors rationing: all healthcare is "rationed" in a manner of speaking:  when demand outstrips supply for any commodity or service, some will have, and some will have not. The problem people have with government-run medical care, then, is not rationing per se, it is who will do the rationing and how.

In other words, the real problem healthcare critics have with Dr. Berwick’s statement is not so much the word "ration," it is the word "we." In fact, a recent blog on the State of Arizona’s recent cuts in certain Medicaid services makes this additional point as well: why is it that when the government rations care, it is a neutral "budget issue," but, for some reason, when insurance companies ration care, they are immoral and unfeeling?  How is one route more "fair" or "just" than the other?

The bottom line is, healthcare in America has always been more available, to greater and lesser degrees, to those who can afford it, than to those who cannot. This is not remarkable: the wealthy have greater access to just about everything–food and housing, for instance, which are unquestionably more necessary than healthcare. But for some reason, the advantage the wealthy have over everyone else in access to healthcare appears to strike progressives as acutely "unfair"–or, at least, that is the party line. But even if we accept that argument at face value, how unfair is it, really?

A couple of liver transplant cases presents an interesting contrast about what might constitute fairness. Under the guidelines of the United Network for Organ Sharing (UNOS), donated livers are allocated based upon which matching donee has the most urgent need. But there is a limitation: donated livers are allocated according to the geographic area in which the donation is made.

Thus, when Steve Jobs, the Apple CEO and a California resident, reportedly needed a liver transplant and subsequently obtained one in Tennessee, the tone of several news accounts were rather resentful. The advantage was considered "unfair" to other liver patients, and some contended that he "gamed" the system by signing up on multiple donor lists at multiple facilities–a tactic that requires a considerable sum of money, since each listing requires a full transplant evaluation, and most insurers will not cover more than one evaluation. By being able to afford, out-of-pocket, the additional expenses incurred in signing up on multiple donor lists at the same time, Jobs increased the chance that he would obtain a liver transplant much more quickly. As it turns out, in Tennessee, the waiting time for a donated liver is much shorter than in other areas, and Jobs theoretically leaped ahead of many of the other 15,000 Americans awaiting liver transplants.

But before one can get too worked up about the "unfair" advantage the Steve Jobses of this country may have when it comes to healthcare, comes the case of Johnny Concepcion, reported in the New York Post. This man reportedly confessed to stabbing his wife 15 times and then destroyed his own liver by swallowing rat poison in an attempted suicide, prior to his arrest. Mr. Conception leap-frogged ahead of over 2,000 New York liver transplant patients because his need for the liver was more urgent than theirs; he would unquestionably have died if he had not obtained an immediate transplant. And the taxpayers, it is assumed, are picking up the tab.

It is hard to fault the UNOS guidelines themselves for this strange dichotomy. Their system is, for the most part, economically neutral and, speaking logistically, medically sensible. But is there anything that makes Jobs and Conception more worthy of obtaining the transplants than anyone else? Is there a reason that these two should have obtained livers rather than the 1400 other Americans who die every year waiting for transplants? Cast another way, does the relatively young CEO of a successful American company that employs over 36,000 people worldwide deserve to live more than someone else? Is a murderer less deserving than someone else? However cold it may sound, there are perfectly rational reasons why one might be willing to answer "Yes" to both of those questions.

But liver transplants aside, the comparison of these two cases points out the inherent problem with a system of care in which the delivery and allocation of medical care is supposedly economically blind and in which every single American has "equal" access to medical care. The fact is, there is simply no way to give everyone what they may want or even what they may need. Medical care consumes resources, and there is a limited quantity of those resources, whether it is doctors, nurses, hospital beds, medications, medical devices and procedures, or even money. There simply is not enough medical care–in all its manifestations–to treat and save everyone, as the liver transplant situation makes abundantly clear. Some are going to have to do without. So:  who?

The fact is, deciding what services one ought to or may receive–or even whether one wants any at all–is a fundamental question of liberty. Americans have always possessed the right to decide for themselves whether and what they wanted in terms of healthcare. This is not to say that all Americans have always been able to get whatever they wanted, but, in essence, they have always had the right to get what they wanted, and have accordingly rationed their own care according to when they deemed it necessary to utilize the services of a doctor, what they were willing to pay to receive a particular level of service, and which medical procedures they opted to employ. The Patient Protection and Affordable Care Act, otherwise known as Obamacare, however, changes all that by forcing everyone, with minimal exceptions, to buy health insurance with minimum requirements whether or not they need it or even want it.

This one provision is why so many lawsuits have been filed against the Administration, including a number of suits brought by states on behalf of their citizens. Not only do Americans balk at the thought of the government digging further into their pockets, a great number of them resent the idea of government paternalism. PLF client Matt Sissel, an artist from Iowa who served as a medic in Iraq under the Iowa Army National Guard, filed a personal suit against the administration, stated it: "If we Americans aren’t free to choose how to use our income and resources in the service of attaining our goals–if we’re told what we must buy with the money we earned ourselves–one may question whether we’re free at all." Just on the face of it, if giving money toward a political campaign constitutes free speech, as the Supreme Court has already established, it is difficult to see how forcing people to purchase insurance against their will does not implicate liberty interests that are just as fundamental. The decision to purchase or not purchase a given service reflects our own personal dispositions.

However much progressives resent "the wealthy" (themselves excepted, generally), there is nothing particularly troubling about employing money as a proxy for "worthiness" or whatever other standard might be suggested as a means to obtain care. The only ones complaining about the system, when you get down to it, are those who believe they should be entitled to force others to pay for things that they cannot afford themselves. If that is an acceptable rationale for rationing goods, why stop at medical care?

The insistence that creating a "right" to healthcare can somehow supply the amount of care that is needed is simply a utopian fantasy that has no bearing on reality. Accordingly, Obamacare’s sceptics can be forgiven for scoffing at the ambitions and baseless promises of Obamacare’s proponents; their dislike of the law stems less from a lack of compassion than from a surfeit of common sense. No one reasonably disputes the desirability of providing care to those who need it, but even proponents of the new law have come to realize that merely creating a "right" to a service has no beneficial impact on its cost or availability.  What is more, when the government steps into the fray to alleviate pangs of social conscience about who may be suffering, it historically has a negative result:  it tends to dry up those sources of charity that might otherwise step forward to help those in need. 

As matters stand, the choice is upon the individual, whose willingness to pay for insurance reflects a conscious and free decision about the risks he is willing to take with regard to his own health–a choice, incidentally, which he exercises every time he decides what to eat (as the First Lady has been fond of pointing out) or whether to exercise. Obamacare takes this choice away, and, instead, requires the imposition of a top-down mandate from either insurance companies or the government to establish a "fair" set of guidelines in which its one-size-fits-all approach is virtually guaranteed to fit practically no one, since health care requirements from person to person are as individual as fingerprints. In the end, no result can be fair to anyone if individuals are denied the choice to decide, for themselves, just what it is they are willing to pay for.

The question, indeed, is whether we will ration with our eyes open.

What to read next