We Need Death Panels

One of the handy pieces of information that the Republicans passed along to the American people when Congress was debating health care in 2008 was the “fact” that Obamacare* would create “Death Panels”.  The term implied that these would be appointed panels of bureaucrats that would decide if your Aunt Maybelle would live or die.

The truth was that Obamacare created no such thing.

But what if the Republicans were right?  Not right about what the Democrats did, but about what they should have done.  Maybe we do need death panels.

There are many causes of the steady rise in health care costs.  High insurance company profits as well as advertising and administrative costs mean that much of the cost of health care goes to pay for things that don’t even improve the patient’s health.  But even a generous estimate of these added costs puts them at a total of 30-40%, while the rest is actual health care.  So that’s all we could save even if advertising and admin costs were completely eliminated.

But health care costs have been going up by rates way above inflation for decades.  That adds up to costs that have tripled, quadrupled, or even ten-tupled, if that’s a word.  That implies we need to reduce health care costs by 80-90% if we are to get back to the “good old days.”  How could we do that?  And how did we get to where we are today of it isn’t only due to inflated profits and administrative costs?

The real answer as to the cost question is to be seen in the changes in the medical industry itself.  Just the fact that it is now an “industry” where once it was a “profession” involving a man with a small black bag and a few medicines and instruments.  And before that it was a black art practiced by barbers and witches.  Back in the black bag days, there really wasn’t much you could do for a patient, so there was little you could charge for.  No anesthetics, no antibiotics, no x-ray machine, no CAT-scans or MRIs.  And without all the science and technology, there were few specialists.  No x-rays means no radiologists and without our current knowledge of the heart, no cardiologists.

As medical knowledge has grown, it has multiplied the things that can be done to help the sick or keep us well.  This partly explains why we live longer.  But it also explains why so many people are having a hard time getting the health care they expect, whether it’s because they can’t afford the private payments required or because the system they are in can’t afford to  pay for the treatment they need for everyone who needs it.

Increased technology and an American culture that often fights death to the bitter end has been responsible for so much of health care costs being expended just before death.  Thirty percent of all medicare spending happens during the last year of life.  While the end of life is a difficult and emotional time, we may need some neutral party to provide perspective and try to reduce the amount of resources spent on the dying so that more can be spent to keep younger people healthy.

Countries that have a single government-run system that doesn’t charge for treatment have to find some way to limit the costs of all the technology and procedures that could be performed.  In Britain, where I live now, the NHS is a single-payer system that covers everyone.  When you go to your doctor, there are no forms to fill out, no payment required.  Usually you can be seen by a doctor within a day or two.  But, from what I hear, sometimes there is a wait for a procedure or a test, sometimes several weeks or even months.  And sometimes they simply say no, you can’t have that, because it has been decided that as a policy, the NHS doesn’t offer that, or only offers it to people who meet certain criteria.

Sometimes the criterion is that the patient must be sufficiently sick, as in maybe you can’t get dialysis or a kidney transplant until your kidneys are in really bad shape.  Or in some cases, it’s the opposite: you can’t get a procedure because you’re too sick or too old, such as a heart transplant for someone over 80 or a new liver for someone who is an unreformed alcoholic.  These are ways of rationing health care by giving certain things only to those who need it most or to those who stand to gain the most from it.

Who makes these policy decisions on who gets what?  Well, the policy is set for the system as a whole, not on a person-by-person basis.  And it’s set by a commission called the National Commission for Health and Clinical Excellence (NICE) that takes into account the costs and benefits of the available procedures and medicines in deciding which will be approved.

So NICE has the power of life and death, not on a personal basis, but overall in the NHS system.  Individual doctors and administrators are responsible for applying the policies to individual patients.  Of course, there is often some wiggle room, but NICE is the closest thing I know of to a death panel.  But by deciding that some cannot get unlimited treatment, they give others a chance to live.  Hopefully, it all works out so that the system does the most good for the most people with their limited budget.  It all seems reasonable, and it has proven to be a very effective way to keep costs down and still have very good outcomes.

The problem of course comes when emotions get involved, when people use terms like “death panels” to scare people, or especially when real people get sick and they and their loved ones can’t understand why the doctors aren’t authorized to do absolutely everything to make them better.

In the past couple years there was a drug that NICE said was too expensive (about 50,000 pounds or $80,000 per year per patient) for the benefit it had, so they did not allow its use.  But those that it would benefit started a very noisy public campaign to get it accepted, and eventually to was.  In relenting, the NHS said that since only about 50 people per year would need this drug, it wouldn’t be too much money.  So the process is affected by politics and public opinion.  But this is a democracy and maybe that kind of responsiveness is a good thing, taken in small doses.

Overall, the system works.  The NHS helps the huge majority of people who need it every day, and in a timely fashion and with very little red tape and no regard to wealth.  But it only can do so by settings limits.

The NHS covers everyone in Britain for half the cost per person that the US health care industry costs per person.  Put another way, health care is 8% of the British economy while it’s 16% of the American economy.

In the US, we will need to eventually limit who can get what procedure or medicine.  It’s the only way to reduce costs.  We could do it and still have private health insurance.  But whether it’s a public entity or a series of private ones, we need death panels soon.

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*The Republicans used this term pejoratively, but it has become mainstream enough that I consider it to be the best shorthand term for the Affordable Care Act.

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