Friday, January 4, 2013

Mortality, Money and Other People

The data might not be this clear-cut, but clearly the US is an outlier.
How much is your life, or your health, actually worth? I'm sure you'd put a pretty big number on it. If, for example, you needed to borrow $100,000 to cure a chronic, life-altering disease, I would bet you would do so. Where you place your personal cutoff point when health care is no longer worth the money will vary, but at some point almost everyone will decide that it is better to accept your mortality than to expend your family's wealth in pursuit of life-extending care.

But what if I re-phrased the question? What if I asked how much your life and your health should be worth to some third party who is obligated to pay for your care? It is much less likely you would say, "you know, the government/insurance company has wasted enough money on me, it's time to let go." No, if you are entitled to care from someone else, you will want as much of it as you can get.

I think the above chart (which, in updates to the blog posts where I originally saw this now point out, is a display of GOVERNMENT spending, and may have other inaccuracies) is showing what happens when that psychological truth is given free reign. In the other countries shown, there is an understanding that the government will impose limits on what will be paid for in the interest of fairness and frugality. In the US, by contrast, there are very few limits. This leads Matthew Yglesias to argue that the much-maligned death panels are actually just what we need. As he puts it:
The "death panels" charge was a potent one for a reason. But not only is this health care spending on the elderly the key issue in the federal budget, our disproportionate allocation of health care dollars to old people surely accounts for the remarkable lack of apparent cost effectiveness of the American health care system. When the patient is already over 80, the simple fact of the matter is that no amount of treatment is going to work miracles in terms of life expectancy or quality of life.
To clarify, again, Yglesias was writing when he thought the chart captured ALL healthcare spending in each country, but surely adding in non-government spending on elderly patients would not invalidate his general point. Namely, that the decisions other countries make about what care is economically justifiable, which we would call "death panels", are the only way to constrain the growth in healthcare spending when the government is footing the bill.

But the reason the death panel argument is so potent is that we in the US understand healthcare as an entitlement, full stop. Politicians have sold Medicare, Medicaid and now Obamacare as a guarantee of full care. Think about this statement by President Obama: "I'm running because I believe that in America no one should go bankrupt because they get sick." That is a pretty remarkable statement, when you stop and think about it, because healthcare is enormously expensive. And as a practical matter, he doesn't mean it: someone who opts for experimental procedures, who tries a costly drug to tread a disease for which it is not indicated, or even someone who chooses a doctor outside of their insurance plan can all still go bankrupt. What he really means is that no one who follows the rules and limits the government imposes on healthcare will go bankrupt because they get sick, but that's not what most people hear. And so when the government tries to impose or extend those limits, people get very angry. And, as has been noted extensively in political commentary, older people vote.

There isn't a happy ending to this story, because people don't like giving up something they think they've been promised. But the only way out of the healthcare mess we're in is to make people feel they're making a financial tradeoff when they consume healthcare. One simple suggestion: the government could give tax credits (or even cash awards) to seniors who are among the lowest consumers of Medicare. Eventually, we could seek to establish a lifetime dollar target for an individual's government health benefits. People who die under that number would pass on some percentage of the difference to their estates. Or, we could provide an annual grant to seniors to buy coverage, and they pocket the difference if they find a cheaper option. (This is essentially Paul Ryan's Medicare reform proposal.) 

None of these changes would be painless, and there is a large contingency that wants to maintain the status quo no matter the costs. But a system that pretends there are no limits on what we can afford to cover, and implies there are no limits on how much care it is even rational to get, encourages people to seek out the maximum amount of care instead of the care that makes sense for them, their families, and their finances.

I know, in writing this, that I might be thought cruel. In other words, that I'm saying we should let people die if they're poor. But I'm not: what I'm saying is by creating a system that encourages the view that you should do everything possible to stave off death, no matter the financial or personal toll, we've driven people to disbelieve in their own mortality and have outsized expectations for what medicine can do. In contrast, I would recommend this piece on how doctors die: people who truly understand medicine, health and the human body are much less inclined to seek end-of-life care.

There is dignity in accepting when our life has run its course. One of the under-discussed benefits of giving more control of our health decisions back to us is that we will more clearly make our own decisions about when to keep fighting and when to let go. With no death panels required.

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