Rationing Health Care

I'm back from a lovely weekend, visiting my sister Susie and her husband Bob in Takoma Park, Maryland, and taking in the fireworks display in our nation's capital--a little muted by low-lying clouds (aka light rain), but maybe that's some sort of metaphor for our times.

Susie and I spent much of my visit viewing reels and reels of 8 mm movies, taken by our father, Alex, between about 1950 and 1966. So many birthday parties (there are four of us Strasser girls) and miniature train rides and pony rides at the Pittsburgh Children's Zoo and children (including some totally unrelated Dutch kids in Amsterdam) on swings! And a lot of really, really bad photography. This is not art; more a kind of obligatory "this is what fathers do" documentation of mid-twentieth-century family life.

But thinking about Alex, combined with reading a long article about the high--perhaps socially indefensible--cost of a new cancer drug in Sunday's New York Times, led me to muse, once again, about the cost of health care. More specifically, on the question of how much extension of whose life is worth how much money.

When my dad was in the hospital in Madison in the fall of 2002, being treated (unsuccessfully) for a staph infection that he contracted after hip surgery, he was quite adamant that I should read a particular book that presented the argument for rationing health care, spending more on pregnant woman, infants, and toddlers and less--much less--on the elderly. The book pointed out that, in our present system, by far the lion's share of expenditures goes toward keeping old people alive for the last six to twelve months of their lives.

My father, who was 84 at the time, was quite explicit about his belief that the focus on keeping old people alive was an abomination. He, himself, had a living will and a healthcare power of attorney, and made it clear to his wife and his daughters that he did not want any extraordinary measures taken to prolong his life. When he was trying to refuse a diagnostic CT scan on the grounds that it was too expensive a procedure for a man his age, I remember saying, "That may be good social policy, but we're not talking policy reform here. We're talking about you." He finally gave in.

(Despite his resistance to extreme--or even not so extreme--medical treatments, and his careful advance directives, he was subjected to resuscitation efforts that left him severely disabled after his heart stopped and his brain was deprived of oxygen for more than fifteen minutes. We had to argue with the hospital to withdraw life support--an argument that, ironically, we won only after I described to the chair of the ethics board how intensely my father insisted that I read the book about rationing health care. But that's another story.)

The Times article reminded me of that argument about the CT scan, and about the different perspectives that even a single person (like me) might have about rationing health care. The article raised the question of whether it makes sense to spend as much as $50,000 or $100,000 for a cancer treatment that may only extend a patient's survival by four months. In the scheme of things, four months is a tiny amount of time, a tiny fraction of a normal life span. Like Alex, I really do think it makes much more sense to invest that kind of money in prenatal and early childhood care--and even on young adults who can expect many more years of productive life--than on terminal cancer patients. But as a cancer patient who has now outlived her prognosis by four months thanks to very, very expensive treatments paid for by insurance and by the American taxpayers who fund Medicare, I can tell you that every good month--heck, every good day--is precious. (So thanks, you taxpayers out there.) And even if I didn't have cancer, I and many of my friends have already passed the arbitrary magic number--60, or 62, or 65--that in many rationing proposals would make us ineligible for open heart surgery or other very expensive treatments. That's a much more sobering reminder of mortality than becoming eligible for Social Security or Medicare.

In the long run, I suspect that rationing health care may be necessary. (In fact, one can and probably should argue that rationing exists now, determined by the market: poor and uninsured people don't get treated; wealthy and insured people do.) But "official" rationing, and the difficult decisions and heartache it will necessitate, can at least be delayed if we take a hard look at cutting health care costs. I recommend the Times article (available here), which explains some of the reasons for the outrageous cost of cancer drugs, as one place to start educating yourself on this issue. And then you might investigate the cost-saving advantages of a single-payer insurance system. They're considerable.

Advocating for Single-Payer Insurance

Early last week, I happened to be driving into my garage, half-listening to WHA, our local public radio station, when Larry Meiller, host of one of the talk shows, announced his guest for the hour. It was Kyle Holen, my oncologist; they were going to talk about the relationship between drug companies and doctors. Of course, I was interested, and as soon as I got into the house, I turned the radio on.

Now, I don't discuss politics during my doctors' appointments. (How many people do?) So I was more than mildly surprised, when a caller asked Dr. Holen why drugs are so expensive, and he replied, "Because in this country, unlike Canada, there are no cost controls." He'd just explained that oxalyplatin, the drug I happen to be on, costs $14,000 a month. I already knew this (as I mentioned in an earlier blog post), but what I didn't know is that oxalyplatin is, at least for Dr. Holen, the drug of first choice for colon cancer patients. There are oodles more cases of colon cancer than stomach cancer in the United States, and $14,000/month treatments for all of those patients must be a hefty contribution to the overall cost of health care, or at least of cancer care.

Dr. Holen went on to explain that in countries with single-payer health care systems, the single payer--that is, the government--is able to use its buying power to negotiate drug prices with the drug companies. Here, however, there are so many clinics, pharmacies, and insurance companies that no one has the power to negotiate prices--and the difficulty of getting all these players to work together and coordinate some sort of price negotiation is pretty much insurmountable.

I would have been thrilled to hear any doctor say this on public radio, but I was particularly pleased that it was my doctor advocating a single-payer health care system. I already liked the guy--he has, after all, kept me alive for three years--but this was extraordinary. A doctor who not only has good (by my standards) politics, but is willing to go public with his opinions!

And then someone else called in to ask if it was true that doctors get all sorts of freebies from drug sales reps. Yes, Dr. Holen said, although he added that he was careful not to accept so much as a pencil from a drug company. He made it clear that even though many doctors insist that free trips and free lunches don't influence their prescription practices, this was unlikely. Why would drug companies spend many millions on this sales technique, if it was ineffective? Dr. Holen described a clinic (outside Madison) where he sees patients once a month or so. At this clinic, lunch is provided daily by drug companies! On the days he's there, however, the other staff has agreed to have a potluck. "I like to think that some day they'll decide to have potlucks even when I'm not there," he said.

As a follow-up, a listener called in to suggest that people might be interested in looking at a website: www.nofreelunch.org. I hadn't heard of the organization, which is focused on breaking physicians' "drug company dependence" by providing arguments and evidence for the link between freebies (including free drug samples) and prescription practices. But Dr. Holen had, and said he contributed to the organization; and then he suggested people might also like to look at the site for Physicians for a National Health Program (www.pnhp.org). PNHP advocates for a universal, single-payer health care system.

These are both great sites. And if you're in Wisconsin, you might want to check out the site of the Coalition for Wisconsin Health, www.WisconsinHealth.org, an organization for which I volunteer. CWH is an affiliate of PNHP; its long-term goal is a single-payer system, but the coalition of over 60 health and social justice organizations understands that this goal may have to be achieved through small, shorter-term, steps, and it has been a strong advocate for the Healthy Wisconsin plan presented by Democrats in the state legislature in the past year.

CWH is also beginning a new state-wide project, Share Your Story. We're hoping that people with horror stories about health insurance, and also with good stories about the benefits of government programs like Badger Care (in Wisconsin) and Medicaid, will let us know that they're willing to take their stories public through the media. We'll interview these people, get their stories, and create a data base that can be accessed by reporters state-wide who are looking for real people with a personal interest in the health care policy debate. If you happen to know of Wisconsin residents with stories to tell, let me know, and I'll pass the information along!

And I really encourage all you readers to comment on, or ask questions about, the economics and politics of single-payer health insurance.