July 21, 2009

the price for a year of life

I think that extending a life by one year is worth $________.

This is the question Peter Singer, professor of bioethics well known for his utilitarian views, wants us to add to the debate on health care reform. In a recent op-ed in the New York Times he argues that we should not shy away from incorporating a structured rationing of health care because we ALREADY ration health care - just not in a good way. He argues that our current form of rationalization is based on who (or whose employer) can afford to pay for insurance (or for good insurance) whereas the type of rationing he would like to see is in the form of deciding what treatments and procedures are or aren't worth the cost (and therefore should or should not be covered by insurance plans). While I am certainly not a strict utilitarian (I'm not sure there are any physicians or people studying to be physicians who really can be, but I'll save that argument for another post) and often do not agree with the extent to which Singer applies this philosophy, in this case I think he is absolutely right.

The current debate about health care reform, and really, any debate about health care reform, has to include 3 phases: 1) figure out how to get everyone covered and what that coverage will mean, 2) figure out how to pay for it, and 3) make it better.

The ideas circulating around congress assume the first part (that everyone should be covered) without changing too much from the current system in terms of how), which is what Singer questions in his op-ed; not that we should not cover everyone but to the extent to which we all need to be covered. Congress is mostly focusing on the 2nd part: of how to pay for a system that will include an additional 50 million people, many of whom were not insured because they were considered too ill to be insurable by companies providing insurance. This is critical because without figuring out how to pay for it, no plan can go into effect.

While the first two parts are fascinating and I will be writing more about perspectives in both - I'm most interested in the third part: how to make it better, because I think it could make both the first and second parts easier. Implementing a system that effectively creates positive changes in people's health will alter A) how we cover people and B) how much it costs us to do it. It affects the first because if you make health care more effective, there will be fewer people in the high risk category whose care the rest of us will have to supplement in our premiums. Better practices affects how much it costs because often the most effective medical procedures (e.g. regular check-ups and screenings, early treatment, asking questions, active listening) are the least costly.

An excellent example is the cost effectiveness of mamography, or breast cancer screening. In an article publishes in the Journal of the National Cancer Institute in 2006...

“The greatest threat to America’s fiscal health is not Social Security, though that’s a significant challenge. It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”
-President Barack Obama

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