Above-Ground Rationing

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.

*   *   *

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?

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6 Responses to Above-Ground Rationing

  1. Why did everyone care about the Chilean miners? For many reasons, of course. But I suspect that the largest were (1) they were an identifiable group (not some population that will be affected by a health policy with some probability, but where the actual victims are not known in advance) and (2) they were extremely sympathetic. The same holds true for Coby Howard.

    I am also reminded of testimony before Congress in the 1972 debates over whether to include an end-stage-renal-disease benefit for Medicare. Here is what one person told the committee:

    “‘I am 43 years old, married for 20 years, with two children ages 14 and 10. I was a salesman until a couple of months ago until it became necessary for me to supplement my income to pay for the dialysis supplies. I tried to sell a non-competitive line, was found out, and was fired. Gentlemen, what should I do? End it all and die? Sell my house for which I worked so hard, and go on welfare? Should I go into the hospital under my hospitalization policy, then I cannot work? Please tell me. If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up?’ (U.S. Congress, House, Committee on Ways and Means, 1971b) The most dramatic moment of the hearing, however, came when Glazer was briefly dialyzed before the committee. This event was widely publicized afterwards and was believed by many to have been decisive in the decision of Congress to enact the kidney disease entitlement. (see http://www.nap.edu/openbook.php?record_id=1793&page=188)”

    The point is that we respond to people when they tug at our sympathies, when they are in full view, and when we see their conditions. This makes me very worried indeed about our ability to consistently and fairly apply resource allocation criteria at the population level, if we only catch glimpses of the effects of policies at the occasional hearing for a specific disease condition. Paradoxically, while it is often thought that knowing the people affected by policies will help us to make better decisions, it may in fact cause us to make decisions for all the wrong reasons. Like you, I find myself genuinely conflicted about these rationing problems, but I think we are not far along enough in our thinking about these problems to know what to say, or how to say it, to the people that are affected by the policies.

  2. Paul Kelleher says:

    Thanks Brendan. I agree with all of that.

  3. Paul Kelleher says:

    I should say that I see episodes like the miners and our reactions to them as something akin to Singer’s toddler/pond example. That is, I don’t readily concede that the principle that dictates saving the toddler/miners *should* generalize to policies involving statistical victims. But I do think that is precisely the question we should be asking, and it strikes me as really interesting that the Arizona decision came to light so soon after the world was galvanized by the Chilean Miners, and yet no one in all the online discussions has pointed to the fascinating and frustrating exercise of comparing the two.

  4. Ben Baumberg says:

    Thanks Paul, I really enjoyed reading the post.

    I’ve heard that the healthcare debates in the US talked about ‘death panels’ in the UK too. Well we don’t have death panels, but we have had lots of public, frustrating discussions about healthcare rationing – with patients groups (usually funded by drug companies) complaining loudly whenever a drug wasn’t approved for use in the NHS. These decisions used to be done by a body called ‘NICE’, but will now be done by GPs on NICE’s advice – as this nice post on the LRB blog describes.

    I’d be interested if there’s any research on public attitudes to healthcare rationing. Not just the usual willingness-to-pay stuff, but – influenced by the applied philosophy literature – the factors beyond lives-per-buck that people think should be taken into account.

  5. Paul Kelleher says:

    Hi Ben, There has indeed, but much of it is still in its early days. I’ll write post or two on this starting next weekend, after my students have turned in their papers on this very topic…. –Paul

  6. Chris says:

    The comparison is striking, as is the example Brendan proposes. It brings to mind other comparisons about the cost of helping those in poverty. Despite the fact that many of poor have stories just as heart-wrenching as the man on dialysis, widespread enthusiasm for spending money to reduce poverty has is lacking (in the US, at least).

    It seems to me that a big part of the reason why is that (again, in the US, at least) many people believe – rightly or wrongly – that many or most of the poor are responsible to some extent for their difficulties. My guess is that one factor that would significantly affect public sympathy for rationing health-care of certain kinds is the extent to which the patient is responsible for his disease.

    I don’t know much about public health statistics, but my impression is that many of the diseases that which consume most healthcare dollars are often partly the result of unhealthy lifestyles (e.g., cancer, adult-onset diabetes). Perhaps if Americans become more health-conscious, they may come to see more of those suffering from such illnesses as partly responsible for their condition and thus more like the poor than like the Chilean miners. Maybe, as with poverty, there will also be some vague division between the deserving ill (e.g., childhood diseases) and the undeserving ill (e.g., emphysema from smoking). This has already happened to some extent with regard to drug abuse: for example, disabilities resulting from drug abuse are generally not considered disabilities for purposes of social security disability insurance.

    Do you guys think that a development of this kind is likely or desirable?

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