(1) The government has taxed money to be spent on healthcare. The more effectively that money is spent, the better.

(2) Society would experience positive sum gains if healthcare spending were done by individuals in a free market, rather than bureaucrats in a subsidy and regulation skewed market.

I think we all agree on these two points. If not, say so.

So who is this non-binding recommendation going to hurt? The women who can least afford to pay on their own, and also the women most likely to benefit!

Peter Singer lays out the case quite plainly in his editorial, “Why We Must Ration Health Care”. I won’t repeat his arguments here (though I find them largely to be sound), but I will try to respond to some of the objections that have been made here.

(1) Breast cancer and PSA screenings are, in fact, cost effective.

Naturally, this is quite controversial since it depends on how one interprets the data (quite a tricky subject). I won’t comment except to say the ACS itself has questioned the value of PSA and breast cancer screenings. The general consensus seems to be that screenings are not cost effective, i.e., we are screening too much, and we should reduce the number of screenings. I would add that, at this point, we ought to be looking at every aspect of health care spending and finding any and all savings we can.

(2) Rationing is cold, and anti-free market.

Specifically, I am referencing Dr. Hartsell’s comment in response to Christine’s argument that the billions of health care dollars we spend on end-of-life care would be better spent elsewhere: “Apart from being pretty cold, this is about as far from free-market thinking as you can get! Wow. I am glad that you know the value of a human life – has to be ‘productive’.”

Unfortunately, this kind of emotional response to cost-benefit analyses is likely what has put us in the current crisis. One political party may suggest some type of cost control, and the other screams “Rationing!” and we keep kicking the can along. It is very difficult to assess the value of a human life, it is a calculation we must make, and do make all the time in public policy. By reducing freeway speeds from 65 mph to 55 mph, thousands upon thousands of lives would be saved, but those benefits must be weighed against the decreases in productivity and lost time for commuters. Some value must be placed on a human life. Peter Singer suggests we do this, for example, by calculating (roughly) the amount of time life is prolonged. While this may be difficult emotionally, I believe that a reasoned (rather than emotional) approach do public policy will result in greater outcomes overall.

I am not sure how Christine’s point is anti-free market. Restricting how public dollars are spent is likely to decrease government costs and require a smaller role for the government. Further, Medicare and Medicaid are already public programs. Blank checks for PSA or breast cancer screenings is no more “free market” than limiting the ways public dollars are spent.

(3) Infanticide-supporter Peter Singer supports rationing.

First, Professor Singer’s arguments about the permissibility of infanticide and his support for rationing should be considered independently. One does not depend on the other, though they are both based on his utilitarian ethical framework. I would not be as dismissive about Singer’s position on (moral) personhood. The question of who should and should not be considered persons is, I think, difficult and complex. Peter Singer’s view, while certainly not mainstream, has garnered a great deal of support within the intellectual community. It should be taken seriously.

(4) Health care is not scarce in the United States. So, Peter Singer’s arguments about rationing don’t apply.

The statement at hand is, “Health care is a scarce resource, and all scarce resources are rationed in one way or another.” Here, “scarce” should be taken in the economic sense: there is some finite limit to the amount of health care we can consume. Further, as we employ more and more resources for health care, we must make tradeoffs between health care related consumption and our other demands. It is true that health care is not relatively scarce in the U.S.; the supply is greater than in Canada, Cuba, or Great Britain; but that does not mean that health care isn’t scarce, period. Singer’s point is that, no matter how we structure the system, health care will be “rationed” or distributed. No matter what system we use, it will always be the case that not everyone will be able to consume as much health care as they would like.

(5) Government shouldn’t be telling people with private insurers what to do.

As Christine has said, the recommendations are non-binding. Insurers can offer to cover more than the recommendations if there is demand. Alternatively, individual consumers can pay for mammographies out-of-pocket. I don’t think this is a case of government coercion.

Beyond his ethically-challenged bioethics, he is just wrong. Health care is NOT a scarce resource in this country. We have more providers, facilities and technology than any other country in the world. There are certain countries in which health care is a very scarce resource – Cuba, for example. There are countries in which health care is a relatively scarce resource – Great Britain and Canada, for example. What do those countries have in common? Total governmental control of health care.

This is a very important point. The problem we have with health care in this country is the method in which those services are purchased. Look at the health care services which aren’t paid for by government or insurance. Plastic surgery and eyecare operate by free-market principles. And – no surprise – these services are offered with the best service and lowest (relative) cost of any medical services.

So, let’s reframe this conversation. Rationing is a responsible solution if government must pay for these services. But government does not have to pay for these services – in fact, for a significant proportion of the women impacted by the USPSTF recommendations, government is NOT the payor. The majority of women ages 40-50 are covered by private insurance. Why should the government be telling them what to do with that insurance?

I think Chrissy and Bill are arguing about different things; Chrissy thinks we shouldn’t have Medicare/Medicaid (I agree) and if we do, we have to make sure that taxpayers get the best value for their money (which can be hard to quantify), and Bill thinks the issue is that older people who have paid into the system and have Medicare shouldn’t be turned away after being productive taxpayers for decades. Both are good points, and hard to reconcile. I don’t think Medicaid and Medicare will be going away for awhile though (continuing to burden the deficit if need be) and so there has to be some sort of decision-making matrix for the money. Personally, I’d prefer that the government be kept out of that, but it’s difficult considering its large stake.

My preference is that there shouldn’t even be a state-sponsored health insurance system. I don’t believe that Medicare should even exist, but given the fact that we do have this taxpayer-funded insurance system, I believe that we should do the same cost-benefit analysis that we should do with any other expenditure. I don’t consider my words to be “cold,” but I do consider them to be realistic.

Specifically why do you think that my statement is not free market? On the contrary, the Medicaid system in the status quo is about as far away from free markets as can be. Requiring other people to pay for the consumption of others seems pretty socialist to me. Medicaid is a pay-as-you-go program, just like the Social Security system. Employees pay into the system their entire working lives, but the government does not hold this money for their individual use later.

For an additional explication, I strongly recommend a recent (July 2009) editorial by Peter Singer, who is a professor of bioethics at Princeton. Among my favorite quotations are the following:

Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. [...] In the public sector, primarily Medicare, Medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals. [...]

If the U.S. system spent less on expensive treatments for those who, with or without the drugs, have at most a few months to live, it would be better able to save the lives of more people who, if they get the treatment they need, might live for several decades.

I’ll address your first post in the morning. Thank you for your commentary.

Wow. I am glad that you know the value of a human life – has to be “productive”. What you neglect to consider is that the octogenarian was very likely productive earlier in his life, paying large amounts of his income to the government for social security and medicare taxes. The government rules and regulations made it almost mandatory that he use Medicare rather than a private insurance policy. The government mandated that he pay into this system for years for retirement and health care, and now that he wants to use those services, this qualifies as “spending thoughtlessly and irresponsibly.”

The US Preventive Services Task Force has revised their comments since the initial publication (probably because of the public furor). The problem with any screening procedure is that there is a cost, but it is not only a monetary cost. There may be the additional non-economic costs of fear, discomfort and anxiety. For a test which can also prevent disease (such as a Pap smear or colonoscopy), the benefit is much easier to see. If a disease is uncommon, the benefit of screening will be very difficult to show – it would have to be an easy, cheap, non-invasive test.

If the disease is common, especially if it is potentially fatal, then screening is more likely to be useful – especially if it is sensitive, specific, non-invasive, easy and cheap. Both mammography and PSA testing are relatively inexpensive and non-invasive (compared to colonoscopy, for example). Prostate and breast cancer are the most common cancers in men and women. Both of these cancers tend to be slow growing, and even when the cancer is metastatic (has spread), some patients will live long periods of time. In addition, the metastatic cancer may not appear for 5-10 years after the initial diagnosis of a prostate or breast cancer. To determine if there is an impact on survival, a long-term study with median follow-up of greater than 10 years is needed. However, the quality of life may be significantly impacted during that time. Most of the cost-benefit studies for screening look at survival as the endpoint, not cancer recurrence. The European study (quoted by Dr. Brawley) does show a benefit in terms of survival and prostate cancer deaths, but a large number of were treated to see that benefit – at 8 years, that is. When this study has a median follow-up of 12-15 years, the benefit is likely to be much higher. In addition, in both the US and European studies, a large number of the men in the “usual care” group actually had screening tests; they were analyzed by the group to which they were randomized, not by whether they received the screening test (this is statistically appropriate, but does somewhat muddy the waters).

http://www.usnews.com/articles/opinion/2009/12/01/benefits-of-psa-test-are-exaggerated.html

http://prescriptions.blogs.nytimes.com/2009/09/03/when-preventive-care-costs-more/

I have one question about this. In countries that have single-payer health care like Canada or the United Kingdom, I think there is obviously a bigger ‘wedge’ between payment and service. Instead of paying for a test, you pay more in taxes.

My question is this: do we see this same effect in Canada and the UK? Do people there order more unnecessary tests than people with more free-market-y systems?

Secondly, this post made me think about this analysis. It shows how screenings (like those done for breast cancer or prostate cancer) can create a statistical illusion of better health care outcomes.