The current issue (cover date June 9, 2011) of The New Republic includes one of the most important pieces I've read about the issue of health care reform. It is by Daniel Callahan (President Emeritus of the Hastings Center) and Sherwin Nuland (Retired Clinical Professor of Surgery from Yale University), and is titled "The Quagmire." Callahan and Nuland succinctly and effectively make the argument that a basic reorientation of philosophy is necessary for U.S. health care if we are not to bankrupt ourselves with increasing health care costs.
As they see it, the essence of the problem is that advances in medical technology (very expensive advances, in terms of cost to patients and government) have produced incremental improvements in survival rates without curing any of the things that eventually kill most of us. The result is that people are living much longer than they did a few generations ago, but their last few years are imposing backbreaking expenses on themselves, their families, and our broader society, without a significant pay-off in terms of quality of life.
The ideal would be for modern medicine to allow all of us to live healthy and productive lives for 90+ years and then to die suddenly without any prolonged or painful illneses. But that's not what our system has produced. Instead, we are keeping people alive to die slowly from various degenerative conditions, and a vastly disproportionate amount of the money we are spending on health care is concentrated on those last few years of life. For example, with rare exceptions of a few kinds of cancer that can be cured or put into permanent remission if caught very early (for example, some kinds of prostate cancer and breast cancer), most of the time people diagnosed with cancer will die from it, frequently after lengthy, painful and exhausting courses of expensive chemotherapy. Nobody has found a cure for heart attack or stroke, just various forms of preventive care and palliative care. Alzheimer's remains largely a mystery, but our health care system, if paid to do it, can keep people with Alzheimers alive for years after their active mental life has essentially ceased.
What Callahan and Nuland propose is a reorientation of our health care system to focus most of the expenditures where they can do the most good – child health, nutrition, sanitation, prevention (vaccinations, for example), and to help people to the extent we can do so to maintain a productive life through their working years, but that we should pretty much abandon high tech efforts to extend life into extreme and painful old age. This means rationing of health care. It isn't exactly "death panels" but some people will scream that slogan as soon as they read it. (Ironically, these will be largely the same people who are demanding massive cuts to Medicare and Medicaid as a partial solution to government deficits, and who opposed the public option as part of health care reform, so that private insurance companies — which in a very real sense do ration care and operate the virtual equivalent of death panels by denying treatment coverage — can continue to take their cut, unnecessarily inflating overall health care costs. People like Paul Ryan, for example….)
Anyway, agree or disagree either in broad outline or as to particular details, I think one must read and think about what Callahan and Nuland, men with excellent credentials and knowledge to bring to this policy debate, have to say. I found much of it convincing.
If saying that “scarce resources must be rationed” constitutes a “paradigm shift,” then every Econ 101 professor in the country should be fired.
But at the moment both the administration and the Republicans seem to think that any change in Medicare that involves rationing scarce resources is a political loser, because the public is not willing to go there. So a paradigm shift would involve getting the public to accept the proposition that the goal in health care is not to preserve life at all costs, but rather to balance out scarce resources in the service of good quality of life.
One small contribution to the conundrum would be to cut insurance rates for people who sign a DNR and/or pledge to enter hospice when the diagnosis is terminal.