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Death Panels and Access to Care

I read an article in the New York Times that underscores my argument that health care insurance does not and never will equal health care access.

Our federal and state governments are being crushed by debt. There are many reasons for that debt, and addressing the reasons for the debt are a necessary aspect of decreasing the debt. For example, if a family household had overdrawn its checking account by several thousand dollars and their credit cards were maxed out, most people would consider it foolish for the family to purchase expensive cars, to donate large sums of money to charity, to go out to eat at expensive restaurants, or to continue purchasing large amounts of weapons to stockpile in its basement. When in debt, there are two options – earn more money or reduce spending. Using the example of the family in debt, perhaps they sell their assets and move into a smaller house. Perhaps they eat macaroni and cheese for dinner. You get the picture.

But if we assume that the family has cut all of its non-essential spending (and many would argue that this part of the analogy fails when applied to state and federal governments), yet is still in debt, then how can the family further reign in costs?

That is the problem with which most governmental entities are now faced.

Arizona has taken a drastic step to reduce costs. It is now refusing to pay for expensive medical care to some Medicaid patients in need of organ transplants. According to the article, the decision amounts to “Death by budget cut.”

Patients such as a father of six (pictured at the right), a plumber, and a basketball coach all need various types of transplants, but are no longer eligible to receive them. The state estimates it will save $4.5 million per year by not providing these services to roughly 100 Arizona citizens. The state also warns that “there will have to be more difficult cuts looking forward.” Read that as Arizona being poised to cut funding for other types of expensive care.

Going back to the analogy about the family – is it morally appropriate to just let family members die because you don’t want to pay for the cost of caring for them?

This fairy tale about providing “insurance for all” is the biggest problem with the health care overhaul. We can strive to provide “insurance” for everyone, but “insurance” is only as good as what it insures you for.

If you are on Medicare and need expensive care or if you live in Arizona and need a transplant, you still have insurance, but that insurance just doesn’t pay for your medical care. Even though patients pay into the system all of their lives, they get nothing out of it when they actually need the care. Ponzi medicine?

If governments were serious about providing medical care for patients, they would create a system similar to the VA Hospital system that is available to every citizen in this country. You walk in the door, you get medical care. Perhaps the care wouldn’t be as good or as fast as care available at private facilities, but care would at least be available.

As the implementation of health care reform takes place, it begins to appear that our new health care system may provide the most benefits to the people that use it the least.

Don’t get sick and you’ll be just fine.

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  1. This is upsetting. Not a surprise though.

  2. With a fixed budget for state provided medical care, you can either limit the kind of care available, or limit who can get it. It sounds like Arizona is trying the former – although Oregon’s experience in trying to evaluate cost/benefit of treatments doesn’t leave me optimistic that they’ll succeed.

    At some point, someone has to be denied treatment. That will always produce heart-wrenching stories of people dying because they couldn’t get care. In this day and age, there is always something more that can be done to try to save a life – at a cost.

    The other choice is to not have a fixed budget. Any glance at graphs of medical costs will show that unlimited medical spending will rapidly require 100% taxation, at which point we’ll *still* have to start denying care to someone somewhere.

    As to Medicare recipients getting nothing after paying into the system all their lives – Medicare and Social Security have always been the equivalent of a regulated Ponzi scheme. The system does not “save” assets (look into the “trust fund” for a good laugh) – it spends today’s contributions to pay for today’s care.

    You can only afford as much care today as you are taking in contributions today. That means care for the elderly today is being paid for by the working young today, not the contributions the elderly gave during their working lifetimes. Those went to pay for care of people who were elderly then.

    Short of it: Some people will be told care isn’t available. Some of them will die as a direct result.

  3. Tarl,

    Your assumption that ‘at some point, someone has to be denied treatment’ is fundamentally evil, and completely wrong. Here is why.

    In the United States you had the Hill Burton Act of 1945 which provided universal health care to Americans. It had a 3% overhead, much like Medicare and Medical, and other government ran health care facilities. This worked perfectly well for us and created the entire health care industry by requiring 4.5 or 4 hospital beds per 1,000 people. We created hospitals, health care was between your provider and you, and you weren’t told ‘you are not a life worth living.’

    However, when we turned into a nation that deregulated everything after the trauma which was the Vietnam war, Health Care became a business. Justice Antonin Scalia defines ‘Share Holder Value’ as a stock holders right to a profit in a HMO than your right as a patient to care.

    If we are to operate in an anti-constitutional manner in which health care is a for profit business, we will have to kill people. If we treat health care as a God given right, then we do not have to kill people to pay for it.

    Imagine, 23 trillion dollars to Wall St. and London, only for them to tell us ‘go kill yourselves for us now’.

    • Do tell me where in the Constitution it discusses health care as a right.

    • Ali:

      The Hill-Burton Act built hospitals, it did not pay for the care that they provided. I agree though that it is essential that your care be between you and your medical care provider, not dtermined by some other third party such as the government. I disagree with you entirely when you say we became a nation that deregulated everything. Our problem is that we have regulated everything. If a patient with Medicare or Medicaid comes into the office, I can not by law negotiate a cheaper price for them. By law my hospital has to pay for the care of the illeagal immigrants that fill the ICUs that force other to pay a higher cost. By law we must pay consultants to monitor our adherence to HIPPA and the thousand other governmental regulations. We are regulated to the point of being incapacitated to actually perform care.

    • Ali writes:

      “Your assumption that ‘at some point, someone has to be denied treatment’ is fundamentally evil, and completely wrong.”

      Ali, resources are not infinite. At some point they run out – you can argue that we can squeeze more blood out of the stone now, but a trivial glance at health care cost graphs should disabuse anyone of the notion that we can pay for everything for everyone forever.

      When we run out of resources allocated to healthcare, people are denied care. There are three traditional ways of rationing health care – simplified into By Whom, By What, and By Waiting.

      – The first is that only some people get treatment.
      – The second is that only some treatments get supplied.
      – The third is that everyone waits in line to get treated, and fewer treatments are necessary because people die waiting.

      If we pretend we have infinite resources, we end up with the third option by default, which is easily the worst of all options.

  4. (I’m removing my name from this post, but as you can tell from my unpublished email address, I’ve posted here many times before, WC)

    We went from being an unemployed family to a family barely scraping by on a part-time income and now looking for a second job for an entire year – everything from what my husband is trained to do to fast food/Wal-Mart, etc. Easily 100 applications filled out and sent in – one interview (where he was second choice and didn’t get the job).

    When we were surprised with a pregnancy, we scraped together funds for an out-of-pocket midwife. Our church is also helping us fund her care. But there were still blood tests that needed to be ordered and filled, and for that I needed to seek out an FP or OB – which we could not afford on top of her fee without missing our rent or utility payments. So I applied for state “insurance” for pregnant women and children. My midwife does not accept this because she doesn’t get reimbursed – she warned me about that from the beginning of our care.

    First my application wasn’t processed (even though my children’s supposedly were). Then they needed additional info but no one told me that. When all was said and done, I was denied the state program… but given medicaid. I was assured by the person on the phone that this was actually a better thing – no copays, no enrollment fees – lots of BS.

    By the time I was approved (I applied at 7w6d – got coverage at 23w2d), I needed to get a thyroid test and prescription, as well as the OB blood work. I spent 3 hours calling doctors in my town, the town to the east, the town to the west and the town two towns to the west. I went through the list of medicaid doctors on the website. Of the 12 offices I called, NONE were accepting new medicaid patients. The receptionist at the 12th office told me of one doctor an hour away that was taking medicaid patients, and I called there for an appointment.

    He was wonderful. He told me what all the other offices had told me – NO DOCTOR HAS RECEIVED **ANY** REIMBURSEMENT FROM MEDICAID IN OVER A YEAR in my state. But he felt it was his civic responsibility to care for patients anyway. He asked if I had any bloodwork in the pregnancy at all so far – when I said no (I had some shortly before pregnancy), he said he couldn’t write up an order for the OB panel because he wouldn’t ever be reimbursed. He did run some other tests that would almost make up the whole panel, which my midwife was fine with as well.

    All this is to say – I’ve always believed it was an issue, and now I’m seeing it for myself. If I didn’t have access to our one vehicle, there would be no way I could have gotten to this doctor at all. If I wasn’t paying OOP for my midwife, I wouldn’t have had any prenatal care until at least 24 weeks of my pregnancy (and this doctor doesn’t do births, so I have no idea if I would have even found an OB by this point). I’m ineligible for a private insurance policy for a (bogus, imo) preexisting condition that’s on my medical records and my husband’s job, though wonderful and supportive, cannot afford to pay for insurance for our family. So I’m normally just an eat-well, exercise and pray I stay healthy kind of person. But now I “have insurance” – just like the rest of the country soon will if things stay as they are.

    Welcome to the real world of insurance for all – care for none.

    • “He was wonderful. He told me what all the other offices had told me – NO DOCTOR HAS RECEIVED **ANY** REIMBURSEMENT FROM MEDICAID IN OVER A YEAR in my state.”

      So…he can’t just let you pay OOP? He can’t just work out a “payment plan” (i.e. you pay him twenty bucks and he writes you a script or a test order)?

      Maybe the issue here isn’t so much Medicaid not paying, as it is doctors who can’t imagine charging anything but premium prices and being paid by anything but Medicaid.

  5. Anonymous-

    You epitomize what is wrong with this country. You describe your financial situation as grim, yet you were “surprised” by what I’m at least hoping was an unexpected pregnancy. As a physician, I am sick and tired of the excuse of “accidental” pregnancies. With the proper precautions, it is possible to prevent 99.9% of pregnancies. Birth control and condoms are far cheaper than caring for a child. Thus, I am left to conclude that you were in fact NOT taking any precautions to prevent pregnancy, and were therefore trying to get pregnant. When you gave trouble making ends meet, in what universe of skewed logic does it make sense to create another mouth to feed? My guess is that you feel it is your right to have a family, regardless of ability to pay. After Medicaid doesn’t pay your OB/GYN, the costs to the taxpayer won’t end there. You will most likely apply for WIC, food stamps, Medicaid for your child, etc, etc, etc. Now you have created yet another burden for the taxpayer. Does that matter to you? Do you care how your actions affect other people or the burden it places on society? Most people on entitlement programs don’t care, otherwise they would be more responsible. You lose your right to procreate if you cannot pay your own way. As this article states, make more money or reduce your expenditures. Just don’t come crying to us when you’ve made your bed.

    • Yes, but many of the Religious Right don’t want women to have access to the morning after pill, birth control pills, or even condoms. In many states, pharmacists can rip up your prescriptions for birth control aids. So what is someone supposed to do under those circumstances?

    • Right, because all birth control has a 100% effective rate.

      You seem to have missed where I said I’m paying for my obstetric care out of pocket. We have cut our budget, eliminated all extras (no cable, to going out to eat, shopping at thrift stores for clothes, buying from the “used by date is today” produce and meat, etc). When my medicaid doctor’s office called me back to come in for a second appointment to discuss my “anemia” (seriously .1 below the cut-off for normal), I instead called my midwife that I’m paying for myself and dealt with it through her.

      I didn’t go to the doctor for anything pregnancy related – as I said, if I had been waiting on the program I actually applied for (NOT medicaid – one where I would have been paying co-pays and enrollment), I wouldn’t have had prenatal care for more than half my pregnancy. I had care starting at week 7.

      I went to have my thyroid tested and my medication renewed… something that I couldn’t do through my midwife or any of the out-of-pocket drop in clinics that I called. The doctor offered to do bloodwork, but that wasn’t what I went there for – I was saving to have that done oop at an independent lab, and I had my pre-pregnancy labs that I also paid for oop as a reference range.

      So it seems that YOU actually epitomize what is wrong with our country – angry about stuff you don’t know about and unable to read. I’ve never been on medicaid before, I’ve never been on foodstamps, never received any other form of assistance. I have no intention of receiving other forms, either.

      And if you have tips for getting an additional job when you’ve already applied every time you see an opening, please feel free to pass those along =)

    • I find your comment cruel and uninformed… It just bleeds the conservative, pull your self up from the bootstraps mentality.

      You are a huge example of what is wrong with America. You completely devalue women, children, the poor WORKING class.

      In other countries, children are VALUED. Mothering women are VALUED.

      Without talking about the myth of the welfare queen (would like to come to my work where TANF (welfare) recipients are required to work 30 hours a week for their benefits?

      The amount of money that prenatal care costs is pennies…pennies.. compared to the thousand of dollars needed to care for a neonatal condition.

      • If you want to talk about the benefit to society to caring for the working poor, and the parenting poor. The working poor, who struggle to pay for their basic needs (food, shelter, BASIC healthcare) are the ones who bag your groceries, process the food you eat, deliver your pizza, clean your office building, serve you your dinner at the cafe, stock your macaroni ad cheese, sell you your clothes, and polish the floors of your local walmart.

  6. I’m really surprised there are only 5 comments on this. Maybe that’s part of the problem. Rapidly evolving technology and medical advances opened up a Pandora’s box. As all these things were introduced and made available did no one anticipate the impact of cost to the system and how it would be determined the most equitable way to choose who gets them? Or at what point things are stopped?
    Antecdotes are the least persuasive of arguements but I watched a friend with metastic breast cancer live just long enough to become confused bedridden incontinent and in pain before hopsice was suggested. She was just 35 with a 4 and 7 y/o. She lived long enough to fragment her family
    with the stresses of caring for her…one side believing there would be a magic potion and the other just tired of watching her suffer. Unfortunately I point my finger at her medical providers. She had insurance that just kept covering everything so they went for it. It actually may have been a blessing if her insurance had run out and they stopped.
    Maybe along with evidence based medicine we should add ethics based medicine.
    But then again we’re all so secular and scientific now we have no way of talking about dying in a way that isn’t frightening. And this is from a person who hasn’t stepped foot in a church in years.

  7. It’s an intellectual debate that no one can win and thus not solve the problem. I’d rather chose to help others on my own will than being forced to give 40% of my check every 2 weeks to god knows where or for what purpose. The entire point of the entitlement system was (past tense) for society to take care of people who lead honest lives, worked hard, and maybe fell a bit short or had a bad turn of luck. Nowadays the system has been saturated with abuse and people who don’t really deserve any sympathy because they chose their own mistakes(see post # 4 above).

    My solution is to start letting individual people decide who they want to help, and let the government make incentives for doing it.

  8. These are tough issues. I have to say that I’m a physician, so I have a stake in this, but the current system is completely dysfunctional. Doctors aren’t hesitant to take Medicaid because they’re greedy, but because it pays less than the cost of doing business! Let’s not forget that the doctor’s income either directly or indirectly supports multiple other people including office staff, hospital employees, etc. You can’t squeeze doctors forever without causing serious disruptions in access to care and hurting a whole industry’s worth of families. It’s simply economic reality.

    We can’t have high quality, universally available care at low cost. Pick two out of three. British style rationing may be inevitable unless we can come up with a sensible policy for expanding care. I fear that any sort of policy will absolutely have to restrict care at least at some level just to be financially doable. I don’t mind making a little less money since this is a social justice issue, just don’t screw new doctors so hard that they can’t reasonably pay back the several hundred thousand dollars on average that it costs them to get educated. Imagine having a mortgage on your education larger than most Americans’ houses. If you really screw doctors’ compensation, pretty soon we will see smart capable people doing something else (like joining consulting firms who are advising hospitals on how to meet the rapidly expanding regulations).

  9. How Medicaid is designed in Oregon
    08/07/09 – The Independence Institute (video 1:30)

    Don’t look, healthcare insurance and sausages are being made here.

    Insurance costs are high in part because government requires that all sorts of extra services are covered by healthcare insurance policies. These services are the ones that can be used every year, to provide income for provider groups. Emergency services don’t have a lobby, so forget about them. So, there is high utilization of accupuncture and health clubs, and little money for rare and expensive procedures.

    Oregon provides Medicaid through government rules drawn up by political lobbying each year. Priorities: High: Stop Smoking, Low: Head Injury

    Health Mandates: Busted!
    08/25/09 – Insureblog by Henry Stern
    How mandates increase insurance costs for Shelley Roche in Maryland. (Video 2:21)

  10. Transplants are cheaper than the care for the chronic organ failure. This is a false if cruel economy.

    It does illustrate what we knew from European experience. Commie Care is Cheap Care. Commie Care killed Princess Diana (no EMT, no jaws of life, no helicopter, no trauma center). If a Princess dies under Commie Care, the ordinary person has no chance.

    As the doc said, try to not get sick, try to not age.

  11. WC – Huey Long created just such a system of Charity Hospitals in Louisiana to care for all those in need.

  12. Ali – thanks for your excellent comment. As for whether healthcare is a “constitutional right”, I find this characterization offensive. Providing health care to all our residents in this country is a moral imperative.

    The only practical way to do it is to require everyone to buy insurance, have a public option, and regulate drug prices. As for those who claim that regulating drug prices will reduce drug company research spending, that’s a load of bull that has been disproved as European drug companies develop new drugs and Europe and Canada regulate drug prices.

    What I find MOST offensive is when people who claim to be christians make arguments about health care not being a “right.” They ignore the new testament verse in which Jesus told people that the way they treat the “least” (i.e. the poor and scorned) is how they treat HIM. This statement by Jesus couldn’t be any more clear and yet they ignore it.

    • If you read hard enough into the Bible you can reason it out that you should self sacrifice yourself until there’s nothing left. How selfish of you then to not give 95% of your paycheck to charity, cause you don’t really “need” more than 5% of it to live, right? So stop trying to use righteousness as a weapon, cause you’re not going to win any battles with it.

      For your second point you are flat out wrong:

      “Price controls seen as key to Europe’s drug innovation lag”


    • Regulating drug prices is often code for forcing companies to sell below cost, which will end drug availability. If it means something like uniform prices with profitability across various purchasing groups, than it would probably work.

    • I agree with alot of what you say. I think alot of health care $$$ goes into administrative costs related to 3rd party payers. (and costs to manage some parts of hipaa and joint commission requirements (expired q-tips?). As an example, when Hipaa marched in our clinic had the joy of giving a our EMR company a $10k check to make a small programming change….anyways

      How about a system that charges people what they can afford? Using a sliding fee model to charge people insurance (or direct medical costs) based on their income, subsidized by gov.

    • Are YOU willing to give all you have to help the poor (like the widow in the New Testament)? Don’t judge others unless you can pass the test yourself.

      • There is a big difference between me deciding to give the local non-profit hospital a donation of $1000 to help provide care for those who can’t afford it and the Feds or the State taking $2000 of my money and using most of it of it to pay beurocrats to figure out how to avoid spending the rest of it to help people.

        The New Testament tells us to give to others, preferably directly. It does NOT tell us to give more of our money to the gov’t so it can dole out smaller pittances for the same purpose.

        And as a patient and someone who works peripherally with the medical field, I think HIPAA should be done away with. I haven’t seen it do a thing for me or the docs and nurses I know except create more paperwork and more ways to run afoul of the gov’t. It certainly hasn’t improved the portability of my health insurance or the quality of my health care.

      • That should have been a reply to the original post, not specifically to maribel.

  13. I guess they will all move to New Mexico, establish legal residency, and get their transplants. At least until NM does the same thing.

  14. Giving money to people you like works fine as long as you either have money or belong to a popular demographic. Non-Christians, mixed-race kids, gay people are pretty much out of luck in the Bible Belt (at least my part of it).

    Also, based on reading various medical opinion blogs: good luck getting people to help you treat your lung cancer if you ever smoked, because you deserve to have it. Ditto diabetes if you’re fat.

  15. The sad reality is that health care is like any other product or service in the world.

    Even though we would like to pretend it is unlimited. It is not.

    Economics 101 teaches us that we use pricing to control access to scarce economic resources. The scarcer the item, or the more resources it takes, the more expensive the cost.

    In the days before health insurance, if you couldn’t afford treatment, and couldn’t find someone to give you charity, you went without the treatment.

    Insurance and Government programs have upset that paradigm. Very few patients, or their families, look at or care what the bottom line cost of their treatment is. “Damn it, I’m sick, and I deserve it no matter the cost”.

    Mandatory Insurance Premiums for everyone is a Federal Tax with a new name. Paid to someone else besides the Government. Whole new levels of bureaucracies working to make a living for themselves and in most cases, profit for companies. Supposedly, this will make the system more efficient. The reality is that we would get more health care dollars if we just raised the medicare tax and put everyone on Medicare from birth. People who can afford Medicare supplamental insurance could pay for extra coverage.

    But remember, the Government is not a source of Charity. The Government at best is amoral. Charity is giving of yourself freely. Charity helps a person become more unselfish. Taxes extracted by threat of Government Force is never charitible.

  16. Oh, such a sad article.

    But, y’know…they *don’t* talk about the burnout case in the next bed over with ten out of ten back pain and he’s allergic to everything but Vicodin. They don’t talk about the family of twelve who’ve all come in for a checkup and free dental work, and they’re communicating through an eight-year-old girl because she’s the only one who speaks English. They don’t talk about the doctor who orders an MRI on everyone who walks in the door because he’s trying to dodge a lawsuit. They don’t talk about the inspector telling you that you need to buy a $10,000 cabinet for every printer because putting the paper in the floor is a trip hazard.

    It’s not like we don’t have money in the system to help people. We just choose to spend it on bureaucracy and frivolousness.

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