It's online now, to be printed in Sunday's Magazine, Why We Must Ration Health Care
It is an attempt to go beyond the political illusions and face some hard realities about health care, what is unique about it along with how it is simply another product, a scarce good with limited resources of supply.
While the entire article is worth reading, on this site by the time it's read this diary will have disappeared from the recent diary list, so I have to excerpt and summarize. Doing this it becomes my own opinion built around this article.
The author, Peter Singer, professor of bioethics at Princeton University, takes on the "framing" aspect of the use of the word "rationing" early on:
In the current U.S. debate over health care reform, "rationing" has become a dirty word. .... President Obama urged (a conference of Democrats) to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintons’ attempt to achieve reform.
In a Wall Street Journal op-ed published at the end of last year with the headline "Obama Will Ration Your Health Care," Sally Pipes, C.E.O. of the conservative Pacific Research Institute, described how in Britain the national health service does not pay for drugs that are regarded as not offering good value for money, and added, "Americans will not put up with such limits, nor will our elected representatives." And the Democratic chair of the Senate Finance Committee, Senator Max Baucus, told CNSNews in April, "There is no rationing of health care at all" in the proposed reform.
Singer has enough confidence in the intellect of his readership to transcend this framing issue, and dives right into his thesis, that rationing, under whatever word is used, is inevitable.
Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for.
Now he shifts into his argument, that while ostensibly we use the pricing mechanism, through the quality of insurance being better for those who are richer, he also says that the corporate tax break alone is a 200 billion a year subsidy...which I can add goes disproportionately to the wealthy.
He fails to mention how much of medical eduction, and all the college and public eduction that are pre-requisites are publicly financed. That's an uncountable number, but one that is vast.
This article is long, several thousand words, and at an early point Professor Singer tries to argue something that he has studied for years, the rationalization of rationing decisions in health care. He looks at how the U.K. does it, with their program given the great acronym of NICE, National Institute for Health and Clinical Excellence. They use various cost benefit formulas to decide what procedures and pharmaceuticals shall be included in their services.
Cost Benefit arguments hold little sway when applied to the individual, as the article describes:
"It’s immoral. They are sentencing him to die." In the conservative monthly The American Spectator, David Catron, a health care consultant, describes Rosser as "one of NICE’s many victims" and writes that NICE "regularly hands down death sentences to gravely ill patients." Linking the British system with Democratic proposals for reforming health care in the United States, Catron asked whether we really deserve a health care system in which "soulless bureaucrats arbitrarily put a dollar value on our lives
It's a shame Singer chose a right wing critic, since it seems to be the Obama policy not to look at NICE, but to claim that such decision protocols will not be needed, something Singer refutes adamantly.
Singer is making an attempt in the rest of this article to define a system of medical care rationing that will be so logical, so inherently fair, that it will be accepted by the American People.
In my opinion, the man couldn't be more wrong; and only his being immersed in his academic field has shielded him from the hopelessness of his quest. What he ignores is that when a man or women is facing death, or experiencing excruciating pain, a rational argument that surveys have shown that their particular parameters of existence, age, overall health or prognosis, indicate the expense of treatment is not warranted will NOT be accepted by them or their families.
Copyright restrictions and readers patience prevents my quoting his complete design for such a rational system of rationing.
What he fails to broach is indicative of how we as a society have not faced certain realities about human nature, and the also limits of any political system to surmount them. Rationing is not a product of social-political systems, even though those ration cards (only remembered by ancient members of this club) are certainly printed by such agencies. Rationing is something that happens whenever there is insufficient supply of something needed by all.
Obama is selling his plan based on the illusion that if only everyone could have a health insurance card, everyone would have adequate health care. This writer rejects this central premise of the current reform enterprise. He offers a solution that would be sure to work, except for minor problem, human beings are not programed cyborgs. Rather we are animals who will do anything to survive. Anything.
So, he says that the present method of rationing, which is relegated to the free market where the rich get the best of everything and the poor get the worst, is not so good. Yet, he seems reluctant to take the bull by the horn, to discuss how this might actually be addressed. His sick human is not like any sick human I've ever know, including myself.
It's ether he feels his plan will prevail, or it's an exercise in academic casuistry that is even a bit much for the elite New York Times. What his article points out, by omission, not inclusion, is that health care is more than seeing a doctor, it is life itself. It is what people strive for no matter their age or condition. It is only superseded under certain rare conditions, such as family affiliation, love of nation, or a belief in a larger truth that transcends this mortal existence.
Among this litany you will not find a cost-benefit analysis. The subject of National Health Care policy is not a wonkish exercise. No, it is the essential description of how a country defines itself. Disease and trauma occur in disparate locations around our country, yet it can be conceptualized as a national catastrophe, the equivalent of an earthquake or a 911, but one that occurs every day.
Right now rather than performing triage, a system that ignores the wealth or status of the victim, but only tries to best match resources of care with the needs of the victim, we do something quite different. We decide who gets care, not by need, but by wealth. During WWII when gasoline was in short supply, like primary care is now, if someone ignored the equal allocation allowed to every citizen, he would go to jail. Now, if someone tries to have an equal allocation of health care, he is called a socialist.
I am using this article in the Times not because I agree with it, but because it refutes the illusion that we can have both an egalitarian system and a free market system. We can't. And on this central point I agree with the writer, and by extension the N.Y. Times editor that printed this.
Sadly, we are building health care reform on this illusion that no such monumental choice of national identity is required. Actually, Peter Singer, has performed a service. He has dared to attempt to replace political framing with the actual choices that must be made. While I don't believe his solution will prevail, at least he gave it a try.
Those who deny that these are the choices do not do a service to our country. Our current medical system did not evolve because of the nefariousness of insurers, big pharma, or doctors....it is an outgrowth of who we are, how America evolved. We are a mix of private enterprise, ravenous greed included, leavened by a bit of government control. That's America, for better and for worse.
At the very least lets face what we are doing here. It could be that we do not have the leadership to effectively overturn all that defined our current system. President Obama has even acknowledged this when he said that "single payer is preferable, but not possible under our current system." It could also be that there is no such leadership possible given our current system of power groupings. This is exemplified by two people who are revolutionary enough to propose fundamental change, Nader and Kucinich, being relegated to the sidelines.
The bill that this site is cheering for happens to be based on illusion, with the major one of "no rationing" perhaps only the greatest of many. Along with this auguring poorly for effectiveness of the reform, it negates the premise of Democrats being the "party of reality."
If we, if our President, if our country... are not up to the task, why should we presume that all will fall into place just because such a bill is passed, when the place that it fell into, all of the structures and institutions of our current system is hardly being touched.
I'm out of space, and readers who have come along this far are out of patience. Now it's your turn.