The "Death Panel" Problem

It is nearly painless to spend someone else's money.

A problem that confounds a rational health care system is the human emotion of care for a person in need, especially when that person is a loved member of the family or appealing or sympathetic to the general public.

In the late 1980's Oregon enacted an innovative and cost effective system to stretch the health care dollars the state received from federal Medicaid funds. Oregon created a list of conditions and medical interventions and decided to fund the most cost effective ones first, then the less cost effective ones, and finally drew the line where the money ran out.  For example, vaccinations and pre-natal care were a high priority (relatively inexpensive, big long term payoff), splinting broken arms (more expensive, but big payoff), etc.  Then on down the list of interventions with less and less utility, until the money ran out.  Breast surgery for cancer was in; most reconstructions for cosmetic purposes afterwards was out.

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The priority list had a "utilitarian" rationality to it: the most good for the most people.  There is only so much money.  Better to spend a few hundred dollars on pre-natal care for a thousand pregnant women, preventing ten tragic cases of babies born with a lifetime of future disability, than spend the same dollars on one spectacular case of heroic interventions but then not have money to do the pre-natal care.   The public universally agrees that government should use tax money wisely and this was an effort to do it. 

Insurance companies, then and now, do this, too.  They cover blood pressure reduction medication, but not viagra.  They cover some drugs but don't cover others they consider too expensive and not sufficiently better than older cheaper ones.  People grumble.

There was a problem: the case of Angela Gesher, age 11, a very ill Oregon girl whom doctors said needed a liver transplant.  Her parents' private insurance would not pay it, and the procedure would cost some $300,000 for the Oregon system, a budget buster.  The transplant was not in the priority list:  very high expense, low certainty of favorable outcome, only one life.  There was a public outcry.  How could Oregon be so cruel?  

Angela's case was resolved by the girl getting treatment at a University of California in San Francisco hospital at University expense, but the political issue has never resolved because what makes sense from a cost and tax efficiency point of view is contrary to what feels imperative as soon as an individual case is particularized.  

Terri Schiavo

In 2001 Terri Schiavo became a breaking news item.  She had been in a persistent coma-like condition and her husband wanted to take her off the life support; her parents argued that she was still alive with mental functioning and hope of recovery.  There was a strong partisan tilt to the controversy with radio talk show and Fox leading the call for her to be kept on support.  The issue became a proxy for the national debate on abortion.  She had a right to life.


This week the issue rose again, with the battle lines drawn against "government rationing" of health care and government death panels, and the British Health Service held up as an example of the "problem with government health care."  A British baby, Charlie Gard, was born with very severe and apparently incurable problems.  British doctors said that heroic interventions would only prolong his suffering.  Charlie's parents protested that they were rationing care and that possibly doctors in the US could do something experimental and useful.  They refused to pay to send Charlie to the US.

The British Health Service was making decision based on the big picture view of what made sense for the whole system: don't squander resources that would do more good if used elsewhere and spending millions of dollars to prolong life for days or weeks is a poor substitute for helping hundreds of people with interventions with proven success.

But parents do not think that way, nor does the public when the patient becomes identified and personal.   A factor in the desire for government to do every single possible thing is the fact that it is paid for by the archetypal deep pocket, the government.   Parents and public cannot accept a situation as hopeless or "all that can be done" when the government, with the potential to spend unlimited money, is choosing to fail to do it.   

Government is choosing to do less that "everything conceivable."  There is only so much money.  
It makes government a decision maker, not simply a third party passive player.   When the insurance company says that something is not allowed (i.e. a drug is not approved in the formulary) people blame a tight fisted insurance company but have little recourse.  One can complain to the government, and the fear of "government death panels" is a potent weapon to use against single payer health system.

Some kind of rationing is apparently happening now within Medicare.  The notion that most Medicare spending goes to hopeless cases at the end of life is contradicted by the data.  It shows that the most expensive interventions--inpatient hospital care--is spent on younger Medicare recipients, people in their 60's and 70's, in which there is substantial potential for future years of life.  Per capita spending on older people declines.

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Insofar as patients and families consider themselves to be "consumers" who have paid for top quality "everything that can be done" service and are therefore entitled to it, then government is criticized when it overtly or quietly rations health care to where it is most efficacious.  That is a confounding problem with the "earned benefit of universal health care" that this blog suggested yesterday.

Air France First Class, NY to Paris

The solution for policymakers may be to embrace a two tier system.   There would be a "good" system, of general public care--perhaps equivalent to Medicare now, or analogous to the public university system.  Then there would be add-on options for prosperous people who wanted the equivalent of private college, first class airfare, or Ritz Carlton treatment.   People would be entitled to care that is lightly rationed for efficiency, but would pay substantially extra for the luxury of the healthcare equivalent of extra legroom in the first class cabin.