Consider two medical interventions:
With the first, you can save 100 people’s lives at a total cost of $4.5 million ($45,000 per life saved).
With the second, you can save 33 people’s lives at a total cost of $20 million (~$600,000 per life saved).
Does having this information help us prioritize scarce resources? I will come back to this question in a moment.
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Time was when the blank in “_____’s Medicaid rationing program….” could be filled by only one word: Oregon.
For those across the pond: Medicaid is the U.S. joint federal/state program that pays for health care for (some of) the poor in the U.S.. There are federal minimum requirements that each state must meet in order to be eligible for federal funds, but each state is free to offer more generous benefits (or the same benefits to more people) so long as it’s willing to pick up a good part of the tab (the U.S. government picks up the rest).
By the mid 1980s, budget cuts had led most states to offer Medicaid benefits only to the very poor, such that most families at 100% of the federal poverty line didn’t qualify. Oregon decided to change this. They did it not by investing significantly more resources, but by curtailing the range of medical services Medicaid would pay for so that they could cover more people. As the American bioethicist Dan W. Brock has put it, Oregon “proposed to ration services rather than people.”
But in 1987, a young boy with leukemia was denied a bone marrow transplant by Oregon’s Medicaid program. The media said it was because of the new rationing regime. Few (if any) reported that since the boy’s leukemia was not in remission, he was not medically eligible for a transplant (i.e. he wouldn’t have gotten it even if he’d had gold-plated health insurance). Nevertheless, if Coby Howard’s leukemia had been in remission, he still would have been denied the bone marrow transplant he needed to save his life. It was reported that Coby’s mother raised $80,000 of the $100,000 the transplant would have cost before Coby died. The firestorm that erupted induced the Oregon Legislature to establish a commission to evaluate the way Medicaid services were being rationed and to make recommendations for changes. What happened after that is of considerable interest in itself, but we must leave that for another occasion.
Fast forward to 2010. Facing a significant budget shortfall, the Arizona legislature voted in March to stop funding certain organ transplant operations for individuals on Medicaid. The cuts became effective on October 1, and now identified Medicaid recipients in Arizona who require transplants but cannot pay for them are popping up in the news. For example, Francisco Felix was in the hospital being prepped to undergo a transplant with a liver donated by a dying family friend when the liver was released to someone else because Medicaid refused to pay for the procedure.
Unfortunately, the reporting on this issue has been spotty. For example, the New York Times ran two articles in the span of two days, one reporting that the cuts were projected to save Arizona $1.4 million per year, the other saying they would save $4.5 million. It has also been reported that the Arizona legislature made its decision in part based on bad clinical data regarding the prognoses of patients who receive the kinds of transplants that were cut. Still, the state faced a $2.9 billion shortfall in an annual budget of $8.9 billion. One can easily imagine a cash-strapped legislature deciding to cut funding even for medical services known to produce extraordinary health benefits for the individuals that receive them.
So how should we think about the morality of health care rationing? This is obviously a huge question on which much has been written, and I fully expect to write a lot about it on this blog. One difficulty is that, at least in the U.S., “rationing” is a four letter word that is used by conservatives to demonize legislative measures that in fact have nothing to do with rationing at all. Those in the U.S.–and perhaps also many of those outside of it–will recall the disgusting display over so-called “death panels” during the 2009-10 effort by Congressional Democrats to reform America’s inadequate health care sector. The nefarious provision in draft legislation that caused the dustup was one that simply would have reimbursed Medicare physicians for time spent discussing end-of-life care preferences and options with elderly patients who want such a discussion, much as they are now reimbursed when they discuss erectile dysfunction with patients who would like a prescription for Viagra. It is an understatement to say that it’s remarkable that this provision, which had nothing to do with rationing, could earn the label “death panels,” while a Republican Governor and Legislature in Arizona can ration medical services for Medicaid recipients largely under the radar. Welcome to America.
Now back to those figures I presented at the top of this post. The first intervention is simply the intervention that Arizona chose not to fund. That is, 100 people are likely to be denied medically necessary transplants so that Arizona can save (at most) $4.5 million next year. What about the second intervention, which would save 33 people at a total cost of $20 million? The number of people saved by this second intervention–33–should sound familiar, since it was recently repeated in thousands of news stories each day for 69 straight days. That’s right: it’s the number of trapped Chilean miners whose ultimate rescue captivated the world on 13 October 2010. And $20 million was one estimate of the cost of that successful operation.
I am one who believes that rationing medicine is both commonplace and morally required. But that does not mean that the rationing that is commonplace is the same as the rationing that is morally required. Still, the ethical evaluation of any particular rationing decision is tricky stuff even for those of us who get paid to think about it. That is why it can be useful to reflect on the similarities and differences between the likes of Oregon’s Coby Howard, Arizona’s Francisco Felix, and those 33 Chilean miners.
I find it remarkable–and regrettable–that the only reference I can find comparing the Arizona episode with the Chilean miners is a blog post by a plastic surgeon in Little Rock, Arkansas who says the decision in Arizona is similar to the “severe rationing of food and water the Chilean miners had to endure to survive.” Surely we can do better than this. Surely the question we should be asking is not “Don’t you agree that rationing is sometimes necessary?” but rather “Can you imagine how the world would have reacted if on October 1–the day the Arizona cuts went into effect–Chile had announced that they had run out of funds and the rescue operation would be ceased?”
Well, can you?