202. "Short Rations" Newsday, Ideas Section, p. 1, (October 21, 1990).
The state of Oregon is proposing to lead the nation in rationing health care - by denying services to the poor.
Oregon has already let at least one person die because it refuse to pay for bone marrow transplants. Now it has ranked 1,600 health care services according to criteria purporting to measure how beneficial they are. (For instance, it ranked the treatment of bacterial meningitis high and impacted teeth low.) It is asking the legislature to draw a line somewhere down that list and to stop payment for procedures that fall below the line. It claims that new information about the success of treatment and how many people would be helped by it will save money that can be used to provide health care to more poor people. Other states are watching to see if this is a way out of the crisis of spiraling health care costs.
It should be made clear from the onset that despite a flurry of rhetoric about the $600 billion a year the nation spends on health care and about how this spending must be reined in, the Oregon plan is completely limited to Medicaid patients - in other words, the poor. The state’s spending for no other group will be curbed. Only poor people will die as a result. In Oregon, as in Britain (whose National Health Service is another model of rationing), those who are well off can buy all the health care they desire, as can those covered by employers’ insurance or their own private insurance.
This matter of elementary social justice must be stressed because rationing is a policy usually favored by progressive people.
The rationing of health care in Oregon is of a radically different nature. It rations not actual health care procedures (say, cosmetic surgery) but reimbursements for them. It thereby favors the privileged and hurts many of the most vulnerable. (The plan exempts, at least as of now, the blind and elderly, partly because they’re on fully federally funded Medicare, not partially state-funded Medicaid, partly because the elderly have more political power than the poor. But still subject to the plan’s limitations are the homeless and the penniless.)
The suggestion that the plan was arrived at democratically after many hearings, town hall meetings and deliberations of the legislature does not justify it. Those who deliberated are largely not persons on Medicaid - not, in other words, those affected by it. If Oregon really wishes to proceed democratically, let it invite Medicaid recipients to vote ast o which services they wish to cut.
The plan stems from a concern not only that we are purchasing “too much” health care, but also that we are buying worthless services. Driven by an irrational quest for immortality, we are said to pay increasingly more for meaningless services, for “health care” that extends life without quality.
In evaluating this claim, a distinction must be made between extending lives of no discernible quality by any measure, and those that some select observers, but not the patients, judge to be of insufficient quality. Absence of quality is found where there is no consciousness, no ability to function as a human being. This is the case of more than 10,000 Americans. With next to no prospect that any quality of life might be resumed, there seems to be a moral justification to discontinue health services to these “nonpersons.” We must ensure, however, that we will not slide down the slippery slope - that is, stop caring for the severely handicapped, the aged, and so on.
The situation is radically different for procedures that are dedicated to extending conscious, caring, creative and often productive lives, even when they impose some travail and constraints. A procedure often cited by analysts as a candidate for elimination is kidney dialysis. Some patients do choose not to have it. However, most vote with their bodies that they prefer being fettered to a machine three times a week for four hours or so and suffering some attending consequences (such as itchy skin, depression and fatigue) to dying. What is ethically unacceptable about that decision? Indeed, it is highly troubling to refuse services to people who can recover to a significant extent.
The right thing to do is to fund all procedures that might prolong life for any patient. The money would come partly from squeezing administrative costs, partly from abolishing operations that have no redeeming merit (such as cataract surgery on Alzheimer’s patients), partly from such pointless expenditures as prizes for 4-H Clubs.
Are we, as a society, so hard up that we should consider rationing? Are we ready to consider rationing resources used to sustain life, without first considering whether or not there are other expenditures of much less merit that can be curtailed? One example: the exploration of Mars and other space visitations ($15.1 billion for fiscal 1991).
One may say that these are federal monies, but so is Medicaid in part. Nor has Oregon put on its list of services to be evaluated items such as re-asphalting roads, indirect subsidies for the lumber industry, expenditures on the legislature and many others. There is no ethical or practical justification for considering rationing one sector of public services and leaving all others unranked.
To put it in more technical terms, if we are to rationalize the distribution of resources, why under-optimize, by straightening out only our health care budget? Why not optimize the whole governmental budget, and look for nonhealth items that could be curtailed with much less sacrifice of people’s needs and preferences?
Finally, if for some reason the savings must come from health expenditures, surely we must first reduce the estimated 22 percent of our health care dollars spent on billing and other administrative tasks and the billions spent on unnecessary medical procedures such as many cesareans, and find ways to curb defensive medicine (say, by limiting the amount lawyers can collect in malpractice suits). It is argued that these cuts won’t stop the spiral in health costs while capping other expenditures would do so. While this is true, morally it is unacceptable to cut life-extending items before tackling those with no such merits.