There was an interesting article in the Times magazine a couple of weeks ago discussing the philosophy of rationed healthcare. Its main point was that we effectively have rationed healthcare now based on income. If your income is high enough, you can get any level of care you wish and if you are poor, you use the emergency room when things get acute. It talked about national healthcare in England where there is a board that determines which therapies the state will cover. Of particular interest is that the board does a cost-benefit analysis of various drugs and therapies and only approves those that can meet a certain test of effectiveness. In particular, it seems to use a test that says that a therapy or drug that can extend your life by one year must cost $50,000 or less per year to be approved. Essentially, they are assigning a value of $50,000 for a year of life.
This is an interesting philosophical problem. What would you pay to live another year? I thought I would share a little of my prognosis/cost equation as an example. The average lifespan for a person with my diagnosis is 21 months. I asked one of the oncologists I originally interviewed how long I would live if I decided not to go on chemo (She was aghast that I asked this question!). She told me 6 months. So, all my treatment and expense, on average, buys another 15 months of life. Of course, there’s a 10% chance that a person with my prognosis could live for 5 years so results vary quite a bit. I’ve already well exceeded the “$50,000 rule” so what does that mean – in England would I have not been covered by the national healthcare? Or would I just have gotten the less expensive drugs? The article does note that the cost of drugs is lower in England than here but didn’t say by how much.
So, this leads to the question of going without insurance. How much would you pay to extend your life for a year? And, not being a bachelor, I am as concerned about leaving my family with sufficient assets after I go as I am about living a short time longer. So, if I had no insurance, how much would I be willing to spend before refusing further treatments for financial reasons? I’ve been lucky so far in that I have good health insurance so I don’t have to make this hard choice. But certainly, many Americans must and do make this choice all the time. Not just for life threatening situations but for routine healthcare that we all take for granted.
Coincidently, I asked my onc recently about the liver transplant that Steve Jobs of Apple just had. Sloan Kettering does not support such a procedure for me, even though my cancer is entirely in my liver. The reason is that the anti-rejection drugs that you take to maintain the new liver lowers your body’s immunity and makes it hard to fight further cancer that may show up elsewhere (or perhaps again in your new liver). They have evidently studied the issue and decided that the procedure isn’t particularly effective over time. Since the hospital makes pretty good money for transplants (something like $250,000 to $300,000), they feel it borders on unethical to collect a large sum for a treatment unlikely to yield the desired result (a future without cancer). On the issue of Steve Jobs, Dr. S said that the form of cancer he’s reported to have is a relatively non-aggressive form, so perhaps it makes some sense for him. But he did point out that having a lot of money to spend on medicine doesn’t necessarily mean you get the best treatment.
So now that we are in the midst of the healthcare reform debate, I think it makes sense to look at these other models – the so-called rationing models. Not just what it means to people with serious illnesses but what it means to people who just need the normal “maintenance” that we take for granted. I wish there was more detailed information available about the proposed legislation. It is supposed to be a 1,000 page bill? That’s longer than a Harry Potter novel! What does it say? Would there be rationing under the proposal and if so, how would that work? Will it bring down the cost of drugs? It seems like the countries that have national health pay a lot less – why is that? I feel like there are more questions than answers and, due to extremist politics, we can’t see the real details. Life is just a soundbite in Washington!
Ok, my rant is done – but this is an important issue with moral, ethical and financial implications for the country. The various forces and parties are lining up on either side, and yet I feel like we still don’t really know what we’re talking about.
BB
