TW: Am going to address health care from a different angle by using a real life example. Ms. Blogger's sister is undergoing chemo. She is using Herceptin which provides an opportunity to compare and contrast our system with others but more importantly frame the challenges associated with universal care and medical costs overall.
Quick context:
1)Herceptin is a "monoclonal antibody," or a targeted biological therapy
2)We will assume it is efficacious
3)It costs roughly $70,000 per patient
4)It has been used widely in the U.S. for about ten years
5)Australia held off approval until 2006 based on concerns about cost/benefit
6)Asked to described the difference in approaches a doctor responded- "If we think it would do some good, we go for it. And then years down the road, we see the evidence of of how much good it does. In a system like Australia's, they have the cost-benefit discussion first."
My questions:
1) Herceptin costs $70,000 per treatment. It is only a part of a person's overall cancer treatment whose other components also have significant costs. How does a society define cost/benefit? At what point does the cost become too high to justify? $700,000? $7,000,000? More? Less?
2) Is the "if we think it would do some good, we go for it" a viable approach given limited resources? If viable for Herceptin, why not for non-health related expenditures such as climate change? education initiatives? etc.
3) Should Herceptin only be available to those with insurance coverage of the type which covers $70K per treatment expenses or should it be available to all who suffer from the relevant cancer(s)? If not available to all, why?
5 comments:
Before my answers, a point on your #2 of context: Part of the case study is that we don't need to assume it is efficacious. We now know it is. The survival rate jumped from 23% to 83% because of Herceptin.
While the US was using it, and building up those 60% more of survivors, Australians were dithering around, and 60% more of their women died.
The problem I see with this is not that someone is having a cost-benefit discussion (though than can be problematic, see below) but that they had it while women were dying in lieu of the treatment.
As to your #1: One of the fundamental differences between the progressive and the conservative vision is the role of "society" in this discussion.
I don't care how "society" wants to define cost/benefits. To the greatest degree possible--and I know it's not 100%--, I want the freedom to determine those for myself and my family. And I most definitely DO NOT want a governing body to have a hand in determining them for me.
2) "Limited resources." We are living in an age when a multi-trillion dollar budget just got passed to "save an economy."
Who is kidding whom about "limited" resources? The sky's the limit, baby, and one day, if we agree that the sky isn't the limit, there are a LOT of other things that would rightly get cut first.
You rail against hypocrisy kind of often. Well, it's hard to be on the other side, watching the insane spending sky-rocket during one summer, and then hear from these same policy makers that we need to be concerned about limited resources.
3) It should be available to all. (Maybe there's a qualification to that if we're talking about treatments for diseases directly related to behavior. But for this one, no patient is more "guilty" than another.)
And it's a straw man to suggest that right now, in the US, Herceptin is not available to all.
If you need it, you get it. There's a 21 year old woman at the cancer center whose parents are both death and she is completely funded by Medicaid and Social Security.
There are grants from Genentech itself, and several foundations that provide financial support for those in need.
Finally, there are indeed people who go into bankruptcy because of medical bills. Not ideal. But they get the treatment.
So let's stop imagining that there are Americans dying needlessly because they aren't insured. People get care.
Do we need to fix the system such that financial ruin isn't as common a result? Yes. Do we need to bring costs down? Yes.
But this last question of yours suggests that without universal care, some poor women go without Herceptin. That doesn't happen.
Re your response to #1- if YOU are paying the $70K, $700K, $7MM etc. AND you do not care about funding other folks in other words a completely free market (like say the market for large yachts) then I say I understand your position. If you are spending other folks $ then we have a problem.
Re #2- you are essentially saying spend limitlessly on health care to the detrimant of almost all other alternatives (understanding btw that some of the stimulus went directly or indirectly into health care). Many progressives would strongly empathsize with your sentiment.
Me, one of the fundamental points of my blog and in particular the health care discussion is that we MUST make choices instead of merely A) asking for limitless spending on our personal preferences or B) avoiding the issue.
3) I cannot state uncategorically that some folks do not get Herp. I suspect some do not.
Regardless I am highly confident many folks either go bankrupt or suffer relatively poor health care due to lack of universal coverage.
Point #1: Or, if I'm paying to be insured by a business that undertakes the risk of insuring me, then I still have a point. Because the transaction is between two private parties (though one of them is a huge business) and we can agree to the terms of the cost-benefit discussion ahead of time.
Could this make premiums go up for everyone else? Yes. But they get to decide, then, whether to continue on with their agreement with said company.
I know that the point and the need is to stop those premiums from going up too much, too fast. But taking away the option to be in this private agreement is not the only solution, and is, at its fundamental level, an uneasy solution.
To tag on to your earlier point about what Obama's plan calls for--e.g. not single payer at this point--again, let's be realistic about the second order effects. A public option now allows a competitor into the marketplace that the government subsidizes, and it would be only a matter of time before private insurance went out of business.
It seems in our discussion that we (both) go back and forth between the practical and the principle. It's in the practical that I'm pretty undecided on some issues and open-minded to solutions.
It's in the principle that I'm pretty well decided: The government should stay out of this. Why?
1. It doesn't do very much very well, and there's no reason to think it would do health care well.
2. The government already does WAY too much, far, far beyond what the constitution says it should do. In my dream world, truly, the government would provide for the common defense and ensure domestic tranquility (e.g. law enforcement) and not do anything more.
3. Most importantly, where there is money spent, there is a moral choice made. The government should not be trusted with making moral choices for us. (Which is exactly what your cost-benefit question is.)
Does government already make many moral choices for us? Yes. This is no reason to establish a system that expands its territory in this even more broadly.
"A public option now allows a competitor into the marketplace that the government subsidizes, and it would be only a matter of time before private insurance went out of business."
TW: The point of a public option or potentially a "private" exchange is to create a mechanism by which folks can pool risk and premiums to negotiate aggressively with health care providers on rates. You assert this option would be "subsidized", this has not been defined and its proponents are well aware of the criticism that it would have an advantage. Why not work on the public option/private exchange concept to make it practical and fair relative to private insurers rather than dismiss it? The goal is to provide those not already in large plans an opportunity to benefit from "large risk pools and combined premiums".
Your ideology of "small government" must be reconciled to practice otherwise it is merely ideology. I favor "small government" as well. I am not supportive of a VA gov't provided system (like the UK) for the U.S. Bridging the gap between the VA system and a free for all like say China is the practical challenge.
Furthermore, getting off topic my "small government" and yours may (I dont know specifically) differ on things like surveillance of private citizens, building more and more prisons, drug legalization, unilateral wars etc. Folks like to be for small government right up until they are not.
Getting back to your response to #1-Anyone's negotiating leverage as an individual within the context of health care sucks. When we are young, healthy and without dependents we have leverage. From there it is all downhill. You are in a system for the rest of your life where age, pre-existing condition etc. are irrelevant. Most of the rest of us are not. You going out into the "free market" to negotiate at this point would be in big trouble.
Furthermore truly private insurers have tremendous incentives to squeeze their treatments down to the minimum.
I don't have the time or know how to discover if the sitting congress, president, supreme court, and any other government bodies will be using this "public option". The bill is just too dang long for me and most congress people to read. I say once health care gets decided, the government should stop offerring the wonderful insurance they have, EMK sure got his original 3 - 6 month terminal diagnosis extended at what cost knowing he was going to die anyway, and go on the public option.
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