I want us to face facts. As much as I am for universal, single payer health care, we will have to face hard choices. Some of these hard choices will be relatively easy to debate. Keep an 89 year old alive for an additional six weeks, or use those funds to perform a kidney transplant on a 40 year old? Some are hard. How premature will a birth have to be before we decide it's too expensive to try and keep that newborn alive?
But we've also got to ask ourselves a fundamental question: how healthy is healthy enough?
I don't think we've asked ourselves this question, and I believe it to be one of the reasons for skyrocketing healthcare costs. The question about delaying a close and inevitable death is easy for most of us. Pull the plug. But as our lifespans continue to expand, we need to ask, how long do we actually want to live, and at what cost?
There are chronic illnesses like osteoarthritis that we currently treat essentially palliatively. We keep the pain to a minimum and the most effective treatments only slow down the progression of a disease. Science is good and getting better. If a $150,000 stem cell treatment can cure osteoarthritis in ten years, will we choose to fund that, or can we continue to advise weight loss, good diet, and good painkillers?
Macular degeneration and presbyopia are both causes of worsening vision as we age. In both cases, glasses are a perfectly effective treatment in all but the most extreme cases. Should we pay for LASIK at thousands of dollars, or a pair of glasses for hundreds?
Finally, how long do we want to live? The best medical treatments continue to get better and we can stay alive longer than ever. Ray Kurzweil is convinced that the first person who can live forever has already been born, and while I'm inclined to leave that to science fiction for right now, centenarians are becoming more and more common and their care more expensive. How much are we willing to expend on the oldest, when this really is a zero sum game, with each dollar being spent on the elderly a dollar that is not spent on the young?
I don't want to shaft people or condemn them to earlier deaths, but I don't think we've asked ourselves these questions with any seriousness, in part because those of us with good insurance are frankly spoiled. Most of us will not need organ transplants or experimental treatments, so we get the treatments we need, even if many of us have to deal with bureaucracy to get them. But even if we're willing to transition to a health care regime centered around early nutrition, prevention, and exercise, we'll still be faced with subtle and painful choices. Once we have universal health care, we'll ultimately be responsible for those choices. We need to start answering these questions now.