Sunday, January 29, 2017

How to Ration Medical Care

Everyone but Paul Krugman knows that socialized medicine means rationed medical care. You cannot provide high quality affordable medical care to everyone without going bankrupt.

Or so it would appear. Now, we read in the Guardian, hardly a shill for the alt-right—that the Great Britain’s National Health Service will be rationing hip and knee replacements. People will be screened according to their level of pain.

The Guardian reports:

A senior NHS official has admitted that funding shortages mean hip and knee replacements will have to be rationed according to pain levels in some parts of the country.

Three clinical commissioning groups (CCGs) in the West Midlands have proposed reducing the number of people who qualify for hip replacements by 12%, and knee replacements by 19%. To qualify under the proposed rules, patients would need to have such severe levels of pain that they could not sleep or carry out daily tasks.

Julie Wood, the chief executive of the NHS Clinical Commissioners, said the proposal was a response to financial pressures.

“Clearly the NHS doesn’t have unlimited resources,” she told BBC Radio 4’s Today programe. “And it has to ensure that patients get the best possible care against a backdrop of spiralling demand and increasing financial pressures.”

This raises a larger, and perhaps pertinent question. How do you compare his pain with hers? How do you know who is in the most pain? Don’t we know that some people have more tolerance for pain and that some people have less? Some people tough it out. Some people cannot. Some people have learned mental maneuvers to diminish pain. Some people might even do the opposite.

If one criterion is whether or not pain causes you to lose sleep, how do you distinguish between those who cannot sleep through the pain and those who are chronic insomniacs?

The brief point is this: the NHS, the crowning glory of Britain’s foray into socialism, is going to ration medical care on partially subjective grounds. Admittedly, some politicians claim that they can feel your pain. They cannot. They are lying to you. Otherwise they might have be able to find a job working for the NHS.


Paul McLellan said...

I think that there is a higher level point. Every society, no matter what mechanism it uses for paying, has to ration care since demand is pretty much infinite, costs are high, and there is a limit (30% of GDP?) beyond which society cannot direct its resources into medicine.

On average, across the population, we all have to pay for our own lifetime's healthcare. The second level discussion is just how to spread it around to make "on average" work. Since clearly some of us will never afford our own lifetime care, that means that some people have to pay more over their lifetime than they consume in care. It's a mathematical identity, not political willpower or something.

Besides socialized medicine, insurance is another way to spread the costs around a population, not the whole population but the insurance pool. But the expenditures an insurance company can to buy medicine make are capped by the total of the premiums it takes in and so it has to ration care too (or premiums have to increase, but there is a limit to how much of that society/companies can bear).

Of course there is lots that can be done to control costs, especially in the US where we actually spend more per capita (across the whole country) than the NHS does but only cover 1/3 or perhaps 1/2 of people between VA, Medicaid, Medicare and people who just never pay their bills.

I am convinced a lot of the problems are due to regulation, and regulation of competition etc. The areas of medicine that are paid out of pocket (laser eye surgery, cosmetic surgery, etc) have apparently declined quite a lot in price. Medicine seems to be the only area where technology leads to increased prices. A sort of anti-Moore's Law.

Ares Olympus said...

The whole question of "high quality affordable medical care" seems entirely subjective. High quality need not mean "high cost" although it does often mean that when you're dealing with investor owned for profit corporations. And "affordable" is obviously subjective, given the range of income and wealth in this country.

Part of the goal of ACA was to make health insurance affordable for people with low incomes, and this, along with expanded medicare, adding government subsides raised the number of people with "affordable" health insurance. But it often still isn't enough so people on the bottom, with say "affordable" insurance with $5000 annual deductibles will often still prefer to not see a doctor at all, because $5000 is a lot of money to spend. And if you can't get people to go to see doctors for preventative care, checkups, and the little stuff, by the time they see a doctor, their health will likely be that much more impaired.

And in fact the ACA showed this "new treatment" effect as people who had possibly gone years without health insurance finally had it, then they could finally get all the surgeries and such that were delayed or avoided, thus causing a spike in insurance usage, and requiring premiums to be raised 50% across even a larger pool, and we know premiums never go down, rather profits simply go up when the spending spike disappears.

And finally what the ACA failed to do is to offer any subsidies for the middle class, so their premiums continued to go up from hard-to-afford to unaffordable.

So you have to think, whatever happens under President Trump, and the Republican Congress, the number of people with health insurance will go down, if subsidies disappear, and especially if the mandate/tax-penalty is lifted. And is there anything Trump and the Republicans can do to lower insurance premiums for the middle class, unless they take the side of insurance companies and let them go back to denying coverage for "pre-existing conditions" and overriding doctor's expert advice with their own criteria.

And once you get to chronic illness, like diabetes, like where people need $1200 of drugs every month to survive, what does "insurance" even mean? Obviously your premiums MUST end up bigger than $1200/month, so there's money left for the nonchronic ones.

And the whole idea of "social" insurance means spreading costs among a wider population and diluting personal responsibility, so perhaps my "good diet" will someday be subsidizing your "bad diet" when you get diabetes, and how can insurance companies ever try to charge higher premiums for people who have poor diets? That would either be subjective or intrusive.

On the other hand, some people are born with chronic conditions having nothing to do with their personal virtues, and there it makes sense to socialize costs, so such people really shouldn't be in insurance pools at all. But if you make such a category, that category is surely to expand over time and soon you'll find a large proportion of the population has some special condition that gives them "above average" health care costs.

Anyway, it does seem like health insurance is a sort of scam, and that its days are numbered. And what I'd expect will come out is "Universal basic health care" that covers the cheaper stuff that keep people healthy and productive, but things like $15,000 diabetes drugs for life ought NEVER to exist except for people willing to pay that themselves. You shouldn't expect others will pay that for you. So at some point you just have to say you got a bad deal in life, and expect you're going to die within a few years, and you have some time to get your will in order.

Of course I know I'm wrong on the diabetes drugs, and someday $15k drugs will sell for $100/month, but that's fine, when costs go down, then people can afford what they can afford.