Peter Steinfels Talks to Daniel Callahan about Health Care Resources
August 16, 2009, 9:54 am
Posted by Cathleen Kaveny
A “founding father” of the field of bioethics, Dan Callahan’s work on the nature, purposes, and limits of health care is essential reading.
Get well soon, Dan!
This is great stuff. And Dan is right…we cannot be afraid to discuss rationing explicitly. Given virtually unlimited health care needs, and limited health care resources, rationing is simply a tragic and unavoidable aspect of the finite human condition. But when we refuse to admit its necessity and explicitly ration care based on the common good, we let other forces determine how our resources are rationed (ability to pay, a disease’s relative level of public sympathy, preexisting conditions, etc.) and this is where tragedy becomes injustice.
Charles, as I have said at every opportunity, when people look around and see that as a society we tolerate a system in which many people are denied genuinely necessary and useful care they will — and should — distrust any talk of rationing because they have a well-founded fear that rationing will be based on something other than genuine utility and need. Only when you demonstrate a commitment to providing for the genuine needs of all sick people will sick people learn to accept that limits on care are based on a belief that specific care is either unnecessary or unlikely to be successful. Discussions of rationing are gun jumping at this point — and are usually the musings of people who are extremely confident that their own needs will be met, whatever else happens.
Barbara. –
Do you think the country can pay for universal care at the level of, say, the care available to federal workers? I know that other nations have ‘universal” care at far less cost, but is the quality (outcome) of their care comparable to the outcome of the care of federal workers?
It seems to me that the word “rationing” should be barred from these discussions. “Triage” would be more accurate, reflecting as it does the necessity at times to give some people preferential treatment
The ultimate questions for our society are: is triage essentially undempcratic? That’s a political question. Also, is triage ever truly necessary in the USA? If so, why and when? These are the harder questions, I think.
I don’t care what the word is used to describe it (though my instinct is that rationing is less alarmist than triage), but we need to do something which acknowledges that any attempt to “demonstrate a commitment to providing for the genuine needs of all sick people” is intellectually dishonest as this simply isn’t possible.
What we can do is make it clear we will ration based on something more ethically defensible than ability to pay, a disease’s relative level of public sympathy, preexisting conditions, etc.
Charles. –
Not everyone agrees that equal care for all is imposssible. This is a question of economics and which economists you think are most competent. Dishonesty isn”t part of the problem as I see it, and calling others dishonest doesn’t advance discussion.
Words do matter. Some words are so emotionally charged they close people’s minds. “Rationing” seems to be one of them
Hi Ann. I didn’t actually say “equal.” What I said was “genuine commitment to caring for the sick.” That’s not the same as saying that there will never be inequities. Just by virtue of where people live and how well educated they are, there will be inequities. And, like it or not, there will be inequities associated with whether your doctor identifies with you, is your neighbor, and so on. However, there will be far less glaring inequities than there are now and medical care will not cause bankrupticy
I have often wondered why people like Callahan (and apparently Charles) are so wrapped up with the necessity of rationing. The inefficiencies within our current system are truly staggering. They are the result of a very pronounced set of financial incentives that can be changed. Knowing those incentives, knowing how to change them, where the pressure points are, etc., requires in-depth knowledge of medical economics and technical expertise. It’s boring, the little picture stuff of a thousand details that doesn’t open up much room for philosophizing about the ethical issues associated with allocating scarce resources. Until the Peter Orszags of the world have their day in the sun, I am just not going to listen to the Daniel Callahan’s of the world.
Words do matter…which is why we should get what Barbara said correct: she said that we need a commitment to provide ‘for the genuine needs of all sick people.’ Unless this is mere sentimentality, it is a virtually impossible goal. The sick have virtually unlimited needs and we have limited health care resources. This means we have to ration resources. Christians in particular should be clued into this given that we should understand human finitude and what it implies better than most.
That said, one need not make the false choice between rationing and reducing costs. We should do both.
Words do matter . . . which, among other reasons, is why it is important not to load the words of others with your own assumptions. To equate a commitment to provide genuine care for all sick people with total satisfaction of the unlimited demands for health care of all people, is, well, it’s one way of arguing without having to actually address what the other person said.
I don’t think we should do rationing (choosing who gets what) until we have made a wholehearted effort to reduce costs. Your assumptions about the need for rationing are just that — assumptions that have not yet been validated. Why you WANT to ration care is what you should be asking yourself.
Now, let me be clear, rationing is not the same as making a determination that certain types of care are useless or even counterproductive or so marginally beneficial that it makes no sense to pay for them as a public benefit. Even if, for a short time, that means some people will get them and some wont’, anyone who has studied practice patterns knows that once a pattern changes for some, it typically changes for all.
OK, Barbara, just to be clear, you’ve now changed your position, right? You originally said that we should make a commitment to provide ‘for the genuine needs of all sick people.’ If you are now saying instead that that the commitment should be ‘to provide genuine care for all sick people’ then I’m very much on board.
What I still don’t understand is how you can be against rationing. You even seem to support it when you say that we should forgo treatments that are only ‘marginally’ beneficial in the interests of the common good. I also want to ask you about our current government run and financed programs: do think that Medicaid should simply pay 100% of every need of every patient until it runs out of money or bankrupts the state until we have better cost controls? If instead (while working for such controls) we should limit what procedures are covered and/or what percentage of the bill is paid, as we are currently doing and would do on an even broader scale if Medicaid is expanded, then isn’t this rationing? And why is it wrongheaded?
No, Charles, I didn’t change my position, I untwisted your words characterizing my position in an extreme and unjustied manner.
How do you like this: “Charles supports rationing. That means he wants to kill your grandmother.” That’s approximately the level of discourse you are engaging in.
What I am saying is that discussions of “rationing” are, as Ann noted, highly loaded, especially when you don’t bother taking the time to even explain what you mean by the term rationing, as you don’t.
Second, discussions of rationing that precede efforts at cost control invoke the specter that rationing has some kind of value beyond trying to use resources wisely through less draconian means. Otherwise, how do you even know what level of rationing is justified?
Believe me, I understand how out of control certain elements of the Medicare program are. But the underlying cause isn’t really what you think it is and it won’t be addressed by “rationing.”
It strikes me that as health care is already rationed, the argument about rationing as a semantic really deflects fro m the divide about those who think about “me” and those who think about all of us (common good) and the political manipulation of that.
Of course, ther eis a limitation on resources, but how we dierect them to most if not all serves to spread the pool and serve those without.
Barbara, I really would prefer to have a friendly argument about the (apparently much more narrow) areas where we disagree…but since you continue to insist that I’m twisting your words (perhaps because of some supposed ‘desire’ on my part to ration care) let me just point out to you that your original words have a meaning…though perhaps not the one you intended. You said we should provide for the genuine needs of all sick people…you later said that we should provide genuine care for all sick people. The former is a dramatically more sweeping (and resource-coming) goal than the latter. What am I missing here?
As I said already, I’m in favor of both rationing and cost-control…this is what I remind my friends who are supportive of the current reform plans. But even if we get all the waste and fraud out of the system, we will STILL have to ration care. This is simply a tragic reality of our finite nature and resources. Instead of avoiding this reality we (especially Christians) should acknowledge it and refuse to let the unjust social structures continue to ration care in the ridiculously sinful ways they are currently.
Let me repeat my question about Medicaid as I’m not sure I got an answer, “Do think that Medicaid should simply pay 100% of every need of every patient until it runs out of money or bankrupts the state until we have better cost controls? If instead (while working for such controls) we should limit what procedures are covered and/or what percentage of the bill is paid, as we are currently doing and would do on an even broader scale if Medicaid is expanded, then isn’t this rationing? And why is it wrongheaded?” (Again, I think waste and fraud need to be taken out of the system…but even then we will be left with the above question.)
Barbara –
You’re right. I shouldn’t talk about “equal” treatment of everyone. Besides the limitations of resources, people’s needs differ, and it is extremely difficult if not impossible to weigh, say, your need for a brain operation against my need for a quaddruple by-pass. It’s an apples and oranges problem: they’re qualitatively different, so how to you measure which oerson gets the preferential treatment (if a choice must be made)?
Some would try to answer these cualitative questions using quantitative criteria. For instance, everyone might have a “bank account” of one million ofr their whole life, and would draw from it until it is exhausted. But this would leave some people dying in the gutters.
This is not to say that all quntitative criteria are morally irrelevant. For instance, it is simply a fact of nature that people are temporal creatures and we can measure the temporal length of our lives. This implies that older people have had *more* life than the younger ones have. Enter the pulling-plug-on-Grandma problem. Should someone who has already live a long life (had more of it literally) have the same claim on scarce resources as a younger person? Spme will argue that Grandma and Grandson are equlaly pdrsons, so we should just toss a coin. Bur I disagree because Grandma (and I myself am in her generation) has alrady had a long life, and Grandson has not. I conclude he should get preferential treatment — which in some cases literally owuld mean pulling the plug on Grandma to save money for treatment of the young.
I think these cases are getting a great deal of attention becausue this particular problem (care of old, dying people) is such a large part of our health-care expendituress. Sure, it might be fairer not to have a pull-the-plug rule at this point in time because we don’t really *know* the economic ramifications of our situation. Howeveer, I think Callahan is right — we need to talk about this particular problem and similar ones involving end-of=life treatment now, because we might discover that No, we really can’t have enought to cover treatments. Yes, it’s a repugnant topic, but that’s no reason not to talk about it.
Before getting into a discussion of rationing, some sort of bureaucratic triage, or other ho-button words (it is true, as others have noted, that words do have meaning), we should first define the problem, and then agree on the goal.
1 – If we are considering how to provide for the 10 percent of Americans that do not presently have health insurance; that is one thing. It is worth remembering that while we need to help the 10% of the nation who do not now have health insurance, the other side of that number is that 90% of the country has health insurance.
2 – If we are considering how to best provide all Americans insurance under the same plan, that is another matter. Nationalizing our health insurance would offer various economies of scale, and possibly other benefots, but it would also require much more thought and discussion, on both the national and local leves, than we have heretofore dedicated to the entire idea.
It is our Christian duty to help the poor; basically, to provide for them. It seems in a nation as materially rich as this, that we can help provide basic medical coverage for our own poor. Moreover, it need not be extraordinary; it need not break the bank.
Enrol the currently un-insured folks in Medicare, increase the Medicare tax accordingly, and leave it at that – for now. This need not be Cadillac health insurance, it would simply need to cover the basics, and that alone would greatly help those who currently have no medical insurance whatsoever.
We should focus on the matter at hand (helping the un-insured) and save for another day the discussion of totally socializing or nationalizing health care.
If we enrol the un-insured in some form of Medicare-Lite, we could then direct our attention to fixing whatever financial and/or systemic problems Medicare has, and to learning how to manage the portion that deals with otherwise un-insured portion of the population. We would have time to learn how to make such a system run smoothly.
Once we learn how to properly operate Medicare so that it provides reasonable medical coverage for the old and basic medical coverage for the working poor, then we could begin considering whether or not it would serve the common good to expand such a system to cover all.
Charles, do you know where the majority of Medicaid expenses go to?
They go to nursing homes for things that cannot possibly be described as “extreme.” The Medicaid population is predominantly young and poor, but in most states, Medicaid expenditures disproportionately (for obvious reasons) go to the elderly, who need very expensive daily support essentially for the rest of their lives. We could take care of the young through other programs. They often get unjustified blame for bankrupting the state when, in fact, the state is trying to resolve a totally different social problem that usually benefits an entirely different class of people. Moreover, the young in the Medicaid program are not typically receiving the kind of “extreme” treatment that we associate with the Medicare program. They don’t need it. It’s predominantly things like OB and peds and chronic medications for asthma, diabetes and high blood pressure that are delivered through Medicaid.
It’s that context that needs to be understood before I am willing to discuss any abstract questions about the financing of the Medicaid program. And every other program has its parallel nuances.
Second, you still won’t define what you mean by rationing.
Third, and this is where I stand, the notion that we have the political will to begin “rationing” public expenditures on individuals but not those who profit by the system is obnoxious. No doubt you don’t want to do that — I never thought you would, but how on earth do you decide what rationing is proper if you haven’t set your budget? What are the criteria for your rationing? When you discuss it this way, you leave yourself open to the interpretation that you see rationing as “good” or at least not value neutral rather than simply “necessary.”
In my book, an amicable discussion does not include trying to characterize what another person has said in the most extreme way possible.
Most of the 90% of those currently with health and welfare benefits get them through their employers, who have (1) no obligation to continue to offer them at all; (2) no obligation to continue to offer what is currently being offered; (3) no obligation to assume any of the cost of providing those benefits.
It used to be that employers had to offer good health and welfare benefits in order to attract, retain and motivate good employees in a market in which many skills were scarce and the employee was in the driver’s seat. Now ……
Currently employed people can lose their healthcare (and pensions/401K plans if they exist at all) at the whim of their employers, i.e., they are ALWAYS subject to layoff. Exception: the very few covered by a union contract. We have seen how safe union benefits have been over the past decade or so.
We have all heard the horror stories of health plans that retroactively cancel someone’s coverage once a serious illness is discovered, under some pretext or another, and leave them on the hook for major expenses.
COBRA for 18 months, in most cases and particularly for family coverage as opposed to individual only coverage, is prohibitively expensive and usually results in the participant either not taking it or cutting the coverage down to bare-bones catastrophic coverage. And after 18 months, then the real fun begins.
The lucky people who afford to buy their own insurance tend to get bare-bones coverage and assume huge out-of-pocket costs for premiums, deductibles and co-pays.
Employers can deduct the cost of providing H&W benefits from their taxable income. Individuals get absolutely no tax break whatsoever for the cost of self-found healthcare.
Employers can work with their insurance providers to structure the plan(s) being offered to include/exclude many types of treatment that might be considered “too expensive” and, therefore, raise the cost of the premiums. And, lest we forget, employers heartily endorse the exclusion of pre-existing conditions because, to include them, also raises the cost of fee-for-service plans. Most HMOs don’t exclude pre-exist, but there is no obligation of which I know that requires them to continue that.
“Individuals get absolutely no tax break whatsoever for the cost of self-found healthcare.”
Forgive me for quibbling, because I agreed with just about everything you wrote, Jimmy Mac, but just in the interest of accuracy: Health Savings Accounts have a tax advantage: deposits in them are not considered taxable income.
Also: there is a real cost, and risk, to employers of having to recruit and train new employees, so I believe that many employers who currently offer their employees health insurance will think very carefully before dumping the benefit (and thereby dumping their employees onto the public option, or the private co-op, or whatever the alternative is going to be) and thereby freeing their employees to work for anyone. (I’m not saying they’re not going to ultimately dump their employees; I think the pressure in particular on employers who are competing internationally will be irreistible. But they’ll at least think real hard :-().
Jim P: I stand partially corrected.
As I read the attached (rhttp://www.ustreas.gov/offices/public-affairs/hsa/pdf/all-about-HSAs_072208.pdf), HSAs presume EMPLOYMENT in most cases. If you are on your own and don’t have a High Deductible Health Plan (HDHP), the HSA FAQs state this:
I don’t have health insurance, can I get an HSA?
You cannot establish and contribute to an HSA unless you have coverage under a HDHP.
I don’t have a job, can I have an HSA?
Yes, if you have coverage under an HDHP. You do not have to have earned income from employment – in other words, the money can be from your own personal savings, income from dividends, unemployment or welfare benefits, etc.
I’m on Medicare, can I have an HSA?
You are not eligible for an HSA after you have enrolled in Medicare. If you had an HSA before you enrolled in Medicare, you can keep it. However, you cannot continue to make contributions to an HSA after you enroll in Medicare.
So, if you are unemployed or “over the hill” and have something other than an HDHP, you don’t qualify for an HSA.
About 30 million are currently covered by medicare, of which approximately 3 million are disabled and the rest eligible because of age. Their premiums for Medicare B & D are not eligible for HSA participation UNLESS they had established an HSA prior to medicare eligibility. They can no longer contribute, but can use the balance to pay for eligible expenses. The withdrawals for non-medical expenses are taxable income, and HSA monies cannot be used on a tax-free basis to pay for medigap insurance.
In looking into HSAs, a substantial number of people who are NOT employed have the advantage of tax-deductible HSA contributions.
“Second, you still won’t define what you mean by rationing.”
Rationing is generally understood as a central authority (usually a government) deciding how to allocate a good for which demand oustrips supply. E.g. 10,000 patients need kidney transplants, but there are only 5,000 kidneys available.
Not having sufficient funds to pay for everything demanded isn’t really rationing per se, although if it is the government who suffers from the shortfall, it possesses the power to respond by dictating how the good will be supplied, which is a form of rationing.
Incidentally, the government can be responsible for creating the shortage of an in-demand good in the first place by imposing a price ceiling. This is probably the effect of Medicaid and Medicare consistently reimbursing medical providers at below-market rates. A certain percentage of medical providers will choose not to accept Medicaid and Medicare patients, and thus supply is not as robust as it would be if the government reimbursed at a market-clearing rate.
That’s how classic economic theory would view it, anyway.
Dumping healthcare plans is most likely not an option for employers of a certain size. However, small and medium sized business may do that, or may elect to not offer them to begin with.
Also, the variety of plans that a larger employer may currently offer might be reduced in number and affordability to their employees.
In this job climate it is an employer’s market. The future most likely will change, but not before a significant number of people who desperately need healthplan coverage from their employers may suffer.
At one time pensions were sacrocanct. Then came 401ks and pensions started to disappear quickly. In these climates, many employers’ contributions to 401ks have been cancelled,”suspended” or significantly reduced. Besides, employer contributions to 401ks presuppose an employee’s contribution.
I understand that some employers now make a token contribution to non-enrolled employees in order to help pass the enrollment discrimination tests that are needed to protect the eligibility of few, the proud and the wealthy to make the maxium level of contributions allowed by statutes.
Jimmy Mac, thx for digging up that info on HSAs, I definitely learned some stuff. There are also Flexible Spending Accounts and Health Reimbursement Accounts. Might be worthwhile for dotcom readers to look into any or all of these.
Flexible Spending Account (FSA): http://financialplan.about.com/cs/insuranc1/a/FlexSpendPlan.htm
Health Reimbursement Account (HRA): http://www.investopedia.com/terms/h/hra.asp
“The sick have virtually unlimited needs and we have limited health care resources. This means we have to ration resources. Christians in particular should be clued into this given that we should understand human finitude and what it implies better than most.”
Hi, Charles, I’m grateful you’ve brought up this spiritual aspect of it. I’ve usually thought about it, though, in terms of humans’ limited medical capability in the face of ravaging diseases or catastrophic incidents, and the consequential need to accept our limitations and mortality. (And sometimes a serious illness even brings about spiritual gifts and strength on the part of the patient). In other words, I don’t usually think about our limits in terms of the limits of our resources, so much as the limits of medical science.
Have any of you heard of “voodoo economics”? The idea was that if we cut taxes, tax revenue would increase, not decrease. Behind this was the idea that innovation would be spurred if people had a greater sense of their won involvement/profit from their work.
Why can’t we apply the same kind of arguments to healthcare? Personally, I think better health is more of a motivator than profit, but that may just be me. If we are being bankrupted by diabetic foot amputations, isn’t it possible that someone will invent an insulin pump that will prevent them? Or do we HAVE to resort to rationing?
The plodding we-dont-have-enough-money has been discredited by supply side economics. Let’s not resurrect it to prevent expanded health care.
Jim, you said:
“I’ve usually thought about it, though, in terms of humans’ limited medical capability in the face of ravaging diseases or catastrophic incidents, and the consequential *need to accept our limitations and mortality. (And sometimes a serious illness even brings about spiritual gifts and strength on the part of the patient).* In other words, I don’t usually think about our limits in terms of the limits of our resources, so much as the limits of medical science.
Jim, however well-intentioned and unobjectionable this is as a philosophical debate, think about how scary it sounds to someone who is actually contemplating end of life decisions, and specifically, that someone will determine whether they get care based on the philosophical view that people “need” to accept the fact of their mortality.
And what I am saying is not that there are no limits, but that statements like this make it sound like there is a positive good in denying care to people who are sick (so they can grow spiritually), instead of admitting that such limits are unfortunately necessary and that we will try to apply them in the fairest way possible starting with care that is judged to be marginal or useless.
I just don’t think it’s fair or wise to debate the question of rationing in a philosophical vacuum that is devoid of the specific context of the individuals and individual programs in which the rationing would take place. I think it frightens the bejesus out of old people, who often already feel marginalized from their family and community, and makes them more determined to get every ounce of care they possibly can.
In other words, it’s one thing to say, “you need to accept your mortality,” and another to say, “there is no chemotherapy that works for metastatic cancer of this type so we are not going to pay for it.”
Might there come a day when we have to limit truly useful and life saving care? Maybe, but we haven’t even begun to use the “lesser” interventions that might help avoid that problem. Horse first, then cart, however more theoretically interesting the cart is in discussions of this nature.
Barbara, we are limiting ‘truly useful and life saving care’ in Medicaid RIGHT NOW. We don’t pay for every every service and/or we don’t pay 100% of every bill. I’ll ask you a third time, and I hope to get an answer, “Do you think we should instead pay 100% of every bill for every ‘truly useful’ medical procedure until Medicaid runs out of money or it bankrupts the state?”
If not, you already support rationing and now we are just talking about what kind.
“Jim, however well-intentioned and unobjectionable this is as a philosophical debate, think about how scary it sounds to someone who is actually contemplating end of life decisions, and specifically, that someone will determine whether they get care based on the philosophical view that people “need” to accept the fact of their mortality.
“And what I am saying is not that there are no limits, but that statements like this make it sound like there is a positive good in denying care to people who are sick (so they can grow spiritually), instead of admitting that such limits are unfortunately necessary and that we will try to apply them in the fairest way possible starting with care that is judged to be marginal or useless. ”
Hi, Barbara, you’re right, it probably would be extremely frightening to spring that unawares on someone who is facing end-of-life decisions and has never thought about, or thought through the implications of, some of these issues. Which is a good reason to encourage people to consider them when they are still of relatively sound mind and body. But as interesting as that is to me, it’s not really the topic under consideration.
Just so everyone is clear: in no way do I want to deny care to anyone in order to make them grow spiritually – that would be an exceptionally cruel approach. I have seen instances in which, facing medical travails that cannot be overcome, patients have found spiritual strengh and resilience. (And I’ve also seen instances in which it broke their spirit).
But I think we’re on the margins of a topic that may be germane. Suppose I am terminally ill, and any care avaiilable to me would fall under the category of (as Catholic moral theologians use the term) extraordinary care; and that this extraordinary care would be extremely expensive – so expensive that the money could be used elsewhere to make a significant impact on the health of other, non-terminally-ill patients. Could the government morally refuse to pay for such “extraordinary” treatment? Or isn’t there a one-size-fits-all answer? As Charles suggests, do Medicare and Medicaid have polices now for such situations?
Since we’re talking about morality, how about honesty as vital to this discussion?
I thought the NPR report this morning on the British backlash against false reporting of theri(somewhat imperfect but probably better )system underscored the “misinformation” (read lying at the source) in the discussion.
Grassley got it wrong about Ted Kennedy if he were Brittish.
Who said the government is going to make end of life decisions?
And, if we had a system more analagous to Brittain or our neighbors to the North would this kind of question be even taken seriously?
But, then, again, the propagandists rule and money decides here!
As someone is 69 let me propose this rationing plan:
Anyone who reaches 65 (or a different age TBD) can will no longer be provided with any heroic care no matter what their illness. They will be protected from pain by palliative care, but pacemakers, heart transplants, etc. will no longer be available to them.
Yes, we might lose a few geniuses along the way, but that’s a tolerable risk.
Younger people who still are (or potentially are) producers of goods, services and economic growth will be focus of major healthcare dollars.
We could also support and provide voluntary life cessation for those over 65 who don’t want to suffer what befalls them.
No, my tongue was not in my cheek! The current system rations care to those with the insurance and/or $$$.
Which option is more rational?