Principle
1 – We need to define clearly the purpose of “health care.”
Until now, our
American health care myth (i.e., that there are no limits) has made it
unnecessary for us to agree on a definition of the purpose of health care.
But as soon as we admit that there are
limits to what we can spend, it suddenly becomes important to define such
a purpose very clearly. We
will need it in order to decide on the range of activities that our
limited health care dollar will have to cover.
I will approach
this problem by proposing what I believe to be a reasonable definition of
the purpose of health care, then considering the implications of this
definition as it relates to rationing.
The purpose
of health care is a) to maintain or restore health when
possible, and b) to optimize functional capacity and compensate for
restrictions in the face of disease or disability that cannot be cured or
prevented.
What this definition does
This definition
implies that the overriding goals of health care are to prevent and treat
disease, and to provide individuals who cannot be rendered disease-free or
disability-free with the optimal opportunity to enjoy the fruits of life.
It charges “health care” with a public health task (searching
for ways to prevent and treat diseases that afflict humans), and with an
individual health task (to optimize the health and functional status of
individuals, whether or not they have diseases that can be “cured.”)
What this definition does not do
This definition
would be considered subversive by some, for it removes from the province
of health care certain activities that many would want to include.
For instance, it does not require doctors to prolong life as long
as possible, whatever the cost in dollars or in suffering.
It does not charge health care with the task of altering the normal
progression of life (e.g., halting the aging process). It does not charge
health care with seeking out or administering treatments that enhance the
lives of people in the absence of disease or disability (e.g., face-lift
surgery or hair transplants). And under this definition, health care would
not be expected to compensate individuals for certain social ills, such as
poverty. This definition
acknowledges limits in what health care can do, and in what it should be
expected to do.
Many would like
to see a broader definition of the goals of medicine that might include
all these things and more. For
instance, many would propose a definition that includes the imperative to
provide individuals with complete physical, mental, and social well-being.
Such an
inclusive definition actively encourages the growing phenomenon of the
“medicalization of society,” whereby various ills not traditionally
considered diseases are being redefined as such. Medicalization presents a
real difficulty for us in the context of rationing. For instance, shyness
might be considered (and is, by some) an illness that reduces a person’s
capacity for complete social well-being. But do we really want people with cancer to have to compete
with the shy for health care resources? (Not that the shy are all that
competitive.)
If we must
ration health care, in my opinion we ought to try to limit the scope of
health care to real, honest-to-goodness diseases and disabilities, and
resist including the growing list of “boutique” illnesses our society
has been creating lately.
You may or may
not agree on this issue, and I respect your opinion either way.
The point is, before we can even begin devising a fair and
equitable system for open rationing, we have to establish a clear
definition of the scope of health care, whether restricted or expansive.
Principle
2 – There should be open competition for resources between “health
care services” and all the other services society must provide.
Having defined
the goals of health care, we now need to prioritize those goals in
relation to all the other services society is expected to provide its
people. These include, among
others, national defense, the interstate highway system, education, the
criminal justice system, and garbage collection.
For those who tend to think in terms of the American health care
myth, it can be difficult to regard health care as having to compete with
the B1 bomber for our limited public resources.
Yet, that is exactly the way it is, and optimal rationing requires
us to recognize it.
Prioritizing
services should be accomplished through an open budgetary process, in
which dollars allotted to health care are considered in relation to all
other necessary expenditures. We
can always increase health care “benefits” by allotting more dollars
to health care, but only at the expense, for instance, of increasing the
class sizes in elementary schools. Having
to consciously make such trade-offs will cause us to reevaluate all our
priorities. It will also, as we have noted, powerfully incent us to reduce
waste across all public services.
Principle
3 – To the greatest extent possible, rationing decisions should be
left to the patients who are directly affected by those decisions.
Rationing
decisions will be inherently more fair, and inherently more acceptable, if
they are made by patients themselves instead of imposed by a distant
bureaucracy.
As
we have seen, “traditional” post-World-War-II American health care
insulated both doctors and patients from the cost of their health care
decisions. Thus, there was no
incentive whatsoever for patients to forego the most expensive testing or
the very newest therapy available, whatever the cost, and no matter how
little the expected marginal benefit.
A
system of open rationing should remedy this “disconnect” by incenting
patients to take the cost of medical services into account when making
health care decisions. The more cost-efficient the decisions patients make, the less
rationing will have to be forced by a third party.
One way to
provide such incentives would be to integrate Medical Savings Accounts (MSAs)
into our rationing system. MSAs
provide a strong incentive for individuals to reduce nonessential health
care spending, and will thus reduce the overall level of imposed rationing
we will have to do.
Under MSA plans,
subscribers (or their employers or the government) pay premiums for a
health insurance policy that carries a high deductible amount (several
thousand dollars), and that is therefore relatively cheap.
The money that is saved on insurance premiums is deposited (either
by the individual, the employer, or the government) to each subscriber’s
Medical Savings Account (deposits to which would be tax-deductible).
An employer who
today spends $5000 per year on health insurance for a worker might, under
an MSA plan, spend only $2000 to buy the worker a catastrophic insurance
policy with a deductible of $3000. The
money the employer has saved by buying cheaper insurance (i.e., the extra
$3000) would be deposited into the worker’s individual MSA.
The worker would then use the money in his MSA to pay for his own
non-catastrophic health care needs; in other words, he would pay any bills
falling under the $3000 deductible of his policy.
If he spent less than $3000 for the year, the money he did not
spend would accumulate in his MSA. And,
after his MSA grows to a certain amount, the money would become his.
He could then withdraw some of the MSA money to use as personal
income, for instance, or to deposit into an IRA.
Because patients
would have to pay out of their own accounts for any non-catastrophic care
they received (and because they would get to keep the money they did not
spend), they would have a strong incentive for demanding efficient care,
and would have a real incentive not to insist on care that wasn’t truly
necessary. Thus, MSAs would
eliminate the disconnect that exists today between the health care that
people demand, and paying for that care.
MSAs would restore to the health care system many of the checks and
balances of the normal marketplace, and erode the notion that health care
is free and limitless. In so
doing, MSAs would reduce society’s overall health care expenditures.
They would render much of the rationing we have to do “rationing
by individual choice,” and thereby would reduce the amount of
externally-imposed rationing that would be necessary.
Later
we will see how MSAs might be integrated into a system of open health care
rationing.
Principle
4 – Coverage for essential health care services is universal.
This is more
than just a matter of fairness (though it is that).
All citizens, and all tax-paying non-citizens, have the right to be
included in our new health care system. The reasons for this should be
clear by now. First, all taxpayers support the health care system with
their dollars, and deserve to participate in it.
Second, under open rationing the limitations that the health care
system imposes on all other public services, as we have just seen, become
quite explicit. All citizens
have to live with those now-obvious broader limitations, and so they
clearly deserve to participate in the health care system that produces
those limitations.
Furthermore, all
citizens (even the rich – and even Congressmen!) should be required
to participate in our system of rationing. Only by including the rich and
influential will the rationing system be designed with the care and
consideration it deserves.
This is not to
say, however, that we should prevent the rich from purchasing health care
services outside the rationing system.
We should not; any system we devise simply will not work if we
artificially restrain people of means from exercising their fiscal
freedom. However, we can
mitigate any disruption that might be caused by such a freedom. First, we
can strive to assure that truly “essential” services will be included
in the rationing program, so, to the furthest possible extent, those who
choose to go outside the system will be doing so for services that really
are “non-essential.” If
it appears that the rich are, in fact, receiving essential health care by
going outside the system, that fact would be an incentive to increase the
priority of those services within the rationing system, or to increase the
health care budget to allow coverage of those services. In this way, the
rich can function as volunteers for “testing” the efficacy of services
that society has deemed “borderline.”
Second, we would be entirely within our rights to charge
individuals a stiff “external care tax” whenever they choose to go
outside the rationing system. The
dollars thus collected could be added to the health care budget, and used
to expand the services available for everyone else. This tax would provide a disincentive for individuals to go
outside of the system (so while they are not forbidden, they also will not
be particularly anxious to do so). Such a disincentive should keep
everyone, including the rich and influential, interested in assuring that
truly “essential” health care services are covered under the rationing
program.
Principle
5 – The rules for rationing should be decided upon in an open,
public forum, and should be as explicit and as clear as possible.
Decisions on the
rules of rationing health care should be made from the perspective of
patients (that is, of the public), not of experts.
Experts of every stripe will be inherently conflicted. Health care
economists will be conflicted in wanting to sacrifice fairness in favor of
maximizing good (more on this below).
Medical experts will be conflicted in wanting to include whatever
services and procedures they perform for a living.
Policy makers will be conflicted in wanting to include services
they can easily regulate. And who knows what the ethicists will want to
do?
Only the public has the right
to make these determinations. This
right derives from two facts. First,
they are paying for the services (through insurance premiums and tax
dollars). Second, they are
the ones who will have to live with the results.
Thus, whatever rationing
methodologies are to be used, they will have to be open, widely discussed,
and based on a broad consensus.
Next:
Principle 6 - ethical precepts
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