Wednesday, March 25, 2009

Health Care Reform

There's lots of talk about health care reform. It's a money conversation. There are calls for reducing administrative costs, eliminating unnecessary "defensive medicine" testing, stopping Medicare/Medicaid fraud, enforcing patent expirations for expensive drugs, and many other good ideas. But what's lacking is conversation about "choices", and about the relative value of life. We're afraid to discuss some of the most important topics that affect health care and the allocation of health care funding.

Americans take particular pride in trumpeting our "personal independence" and "freedom". "Socialism" is a swear word to many of the more affluent Americans who espouse the free market. But, even those on the bottom of the economic ladder are often found crying out for autonomy in many aspects of their lives (while they wait for their free lunch or government check). Unfortunately, we park these concepts when it comes to our own health care concerns.

I like the "free market" idea of pricing health insurance like we price most other insurance - those who choose to take higher risks pay more or get less care. Right now America is beset with numerous "epidemics of choice" - chronic diseases caused largely by voluntary behaviors such as smoking, drug addiction, over-eating, driving too fast or recklessly, etc. These epidemics are responsible for a large part of our nation's overall health care burden, yet we (mostly) allow those who make poor choices to rely on those who act wisely to fund the resulting health care burden. This is not fair - it's not "American".

So, what would I recommend with respect to insurance? Change the rules and establish a grace period for behavior change, that's what. Maybe we won't be able to identify or quantify all the areas of adverse choices, but we certainly can identify some of the big ones, and start there. Tough love - that's what we're talking about. For example, if you are obese you pay a lot more for your insurance (even on group plans) and your deductible for treating weight-related symptoms is increased. If you have DUI or multiple traffic convictions, your health insurance goes up. If you smoke, your deductibles for cancer and heart disease treatment go way up. And, what about AIDS, another preventable disease? When families start to recognize that certain behaviors can be very expensive, those behaviors will be largely curtailed. Overall health care needs will decrease, the overall quality of life will improve, and the system will be perceived as being more "fair". That, at the cost of real pain for those who flaunt the rules and exert their independence in negative ways.

"End of life" care is the second major component of overall health care costs that need to be discussed. So far, all humans have been found to be terminal. The lucky ones age gracefully and go quickly; the unlucky ones age painfully and die slowly. At what point does medical care to extend life become inappropriate? We need to make some decisions as a society, because the time is coming when end of life care could consume a huge and unsustainable part of America's income.

This morning I heard a medical professional say that, by 2050, five million elderly Americans per year will require treatment for Alzheimers, a progressive brain disease. Currently, many millions of Americans are being "warehoused" with chronic physical or mental conditions that make their quality of life problematical at best. I've seen numerous instances where people who wished to die, or elderly people who had no capacity to accept or decline health care interventions, were given expensive medical treatment that may or may not have extended their lives. And, do you remember Terry Shaivo? We all paid the giant hospital bill for care that her husband was not allowed to decline. We need some clear standards that define circumstances where further medical intervention is not appropriate. I'll abide by them - in fact, I'll choose them in advance.

Yes, we need health care reform that focuses on better administration, more effective medicine, and fraud control, but we also need to reform how we treat negative behavioral choices and how we allocate health care resources to end of life situations. It would be nice if our resources were unlimited, but, in fact, choices are necessary. At present, America is paying the bill for illnesses and injuries caused by a multitude of voluntary individual choices. America is also paying to extend the lives of many who, by some definitions, have no life. If we really, as a culture, value freedom and independence, we need to address these matters sooner rather than later - before our country is bankrupted by health care costs run amuck.


Dave said...

Too much to think about. Bad choices that cause the need for medical care, I have difficulty disagreeing with you. The end of life issue - what is the cut off? There are only two logical points. You are diagnosed with a terminal disease and are either treated or not. If you have the money to pay for your care so be it; if not.... Anything in the middle seems to be a value decision that will be decided by people with more money than average. This is a quick response, maybe more later.

Anonymous said...

If Death hasn't changed people's risky behaviours, then I don't know that higher insurance rates will, either.

What I think will happen is (drumroll, please): nothing. We'll carry on as we have been until it reaches a crisis point, then the government will bailout failing companies at taxpayer expense.

Now that there's a precedent, why would any company do it any differently?

Lifehiker said...

Actually, people care a lot more about current consequences than future consequences.

Everyone thinks they will live a very long time until they get a scary diagnosis or have a close call with grim reaper. That's why their risky behaviors seem so benign to them.

But, tell someone that they will have $200/month less to spend if they keep on smoking or weigh more than 200 pounds on their 5'9" frame - that's going to get their attention. They may not be happy, but they are likely to do something. That's a car payment, after all.