Friday, December 2, 2016

How Much is a Human Life Worth: A Question we Need to Answer

With the election of Donald Trump, there has been much speculation about his plans for the ACA- speculation that rose again after the announcement that Dr. Tom Price, MD, is to be appointed as his Secretary of Health and Human Services.  But the reality is that any health plan in the United States- Trumpcare, Pricecare, Obamacare, Hillarycare, and someday perhaps Warrencare or Bidencare will not work because of our collective failure as a society to answer a question that every foreign health system has answered in some way:

How much is a human life worth?

Whether it is Medicaid, Medicare, or private insurance companies- every American health insurance company has variations on two fundamental complaints against it:

1) It costs too much

2) It doesn't pay for enough care

Does anyone not see that these two complaints are directly opposed?  If we want to pay less for health insurance, that means that we need to accept that someone's child, someone's mother, someone's husband is going to have to go without the $300,000 4th-line chemotherapy drug that has a 1% chance of working, if you define working as an extra 3 months of life.  And the obvious question- how much is it worth it for a sick child to live an extra 3 months- is never openly asked and answered.  Instead, families set-up goFundMe pages, and detail battles with insurance company or Medicaid administrator villains.  News media loves to get involved, and spotlight the failures of government agencies and corporations.  We curse them for not paying for the drug, treatment, or therapy for that family.  And then curse them again when our health insurance bills are too high because in the end, the villains caved and paid up.

When the ACA tried to even approach answering this question, simply by funding conversations about end-of-life care, it was decried as "death panels", and shot down.  An "Independent Payment Advisory Board" implemented by the ACA is explicitly banned from "rationing" care, and yet has still drawn incredible fire simply for trying to ensure that only effective treatments are paid for- let alone if they are "cost-effective".

Republicans are deluded when they say that putting patients' "skin in the game" -giving them more choice and control over who they go to- will significantly reduce costs.  It is a common theme of Republican plans including Dr. Price's plan, and one that has been shown in various studies to have little positive effect.  Patients can't tell what is high quality care and what isn't, and in any case patients who have the ability to select between various treatments aren't even the problem.  In 2008, 5% of Medicaid patients were the cause for more than 50% of all Medicaid spending, and I doubt that figure has changed.  Sick people need care, non-sick people don't cost that much.

Democrats instead tout their expansion of insurance to everyone, but ignore the reality that this expansion is doomed to increasing costs and eventual failure unless the question they don't want to get at is answered- what will that insurance pay for?  For many ACA plans, the answer is not that much- to keep costs low, they severely restrict patients' access to doctors, but hide this restriction away.  Instead of openly denying care, they just make it difficult by ensuring that the nearest specialist a patient needs is 30 miles away, and keep patients from the most prestigious, effective, and cutting-edge centers.  I am in remission from cancer, and thanks to my PPO insurance from Baylor I get my care at MD Anderson- arguably the best cancer institution in the world.  It is one that actually makes a difference in outcomes for a select group of patients through access to genetically targeted therapies that are only rumors elsewhere.  But no patient in any Texas ACA plan has such access, unless MD Anderson accepts them as a charity patient- it is simply too expensive.

This dilemma of how much healthcare is worth doesn't even have to get at such life and death issues as cancer treatment.  Should insurance pay for a hernia repair with laparoscopic instrumentation, vs one done in an open fashion with a bigger scar?  How much is 5 days a week of home physical therapy vs 3 days worth for a child whose life expectancy is less than 10 years?  Republicans claim it is here that "choice" will help cut costs, and it actually might in the former situation.  But in the latter, 5 days is usually obviously better than 3 days, and few families have the means to pay for the difference out of pocket.

How much is a human life worth?  Though the question is simple, it hardly easy.  But unless we as a society have a serious conversation and try to answer it, as many foreign countries have done, any attempt at a healthcare plan is doomed to a slow failure.