Who Decides the Extent of Our Health Care ?
Do people have a right to Health Care? Responses to our informal poll on the subject ranged from “No one has a right to health care” to “It’s a basic human right for everyone.” Most poll participants, however, felt certain conditions should be met before health care is provided. If so, who determines what these are?
The question of who decides if and how much health care one gets, hit the headlines recently with the story of “Baby Joseph“. Canadian health officials had ruled that 13 month old Joseph Maraachi, who was suffering from a rare neurological disease and required breathing apparatus, was in a vegetative state and had no chance of recovery. They gave the parents just a few days to say their goodbyes and sign release papers allowing the medical staff to remove the child’s life support. The parents, instead, wanted the child’s immediate medical condition improved with a tracheotomy which, they felt, would allow them to care for him at home. Canadian medical authorities, refused their request. In desperation, the parents sought the help of U.S. medical facilities and was able to transport the child to a St. Louis facility where the tracheotomy was performed. The parents intend to return home and, with the aid of ventilators, keep their child alive as long as possible.
Who decided to terminate life support for the child in the first place? It was Ontario’s Consent and Capacity Board. News accounts referred to them as a “Death Panel” for their refusal to consider the parents’ wishes. But the truth is, systems likened to “Death Panels” are inevitable wherever a government, such as Canada, is the sole provider of health care.
Every publicly supported health care system in the world has an organization responsible for defining what health care services can and cannot be covered by public funds. In Great Britain, it’s the National Institute of Clinical and Health Excellence (NICE) that determines what procedures and circumstances are covered by Britain’s National Health Service. Today, NICE is being reviewed for changes to its organization but, nonetheless, its rationing functions will remain. NICE uses a formula based on the length and quality of life to determine whether a medical procedure is ‘worth’ the cost. Looked at rationally, this might make sense but when it’s our life or a loved one’s that’s involved, it’s brutal.
This is, however, how decisions concerning money or valuable resources are made every day. It’s the people who must pay for something who get to decide what and how much to buy based on whether it’s needed and affordable relative to other priorities. The same holds true for health care. For most working people, that’s their employer or themselves. It’s the government who decides what Medicare covers for older people and it’s the government who makes the decisions for the poor through Medicaid.
Until recently, “Death Panels” isn’t something we equated with health care in the U.S. However, last fall, facing a $1billion budget shortfall, the governor of Arizona, Jan Brewer, announced, among other things, that organ transplants, specifically for heart, liver, lung, and pancreas, would no longer be covered by Medicaid. (Medicaid is the program funded jointly by states and the federal governments to provide health care for the poor and disabled.) When the announcement was made, the charge of ‘Death Panels’ was hurled against the governor and the state legislature. State health officials claimed, in defense, that the transplants did not significantly extend life expectancy. Nevertheless, they are expensive. The costs for heart, lung, and liver transplants are, respectively, $864,700, 496,500, and 529,900 for the first year providing a saving from not covering them at $4 million a year. Dr. Michael Shapiro, Chief of Organ Transplantation at a New Jersey medical center was critical of the Arizona decision , but admitted, “we can’t afford to pay for everything for everyone.”
The explosive growth of Medicaid costs was at the heart of their $1 billion deficit, according to the Governor, citing a 65% rise in 4 years and a 29% share of the state budget. It should be noted that, although transplants are not mandated by Washington, most states cover them. Also, just this week, the Arizona legislature and governor worked out cuts in other places, allowing organ transplants to be covered by Medicaid once again.
Arizona is not alone. Many states are facing budget short-falls with rapidly rising costs of Medicaid. Nevada, Illinois, Wisconsin, Nebraska, Colorado, South Dakota, Kentucky and Washington are among the states attempting various means to bring down the cost of Medicaid. Given other critical priorities of education, security, public safety, and infrastructure, these are hard decisions to make. Texas is cutting rates to medical providers: doctors, dentists, hospitals and clinics. Faced with a 179m budget deficit, Florida is reducing services like therapy, transportation, personal assistance and job training. Kentucky is requiring a medical approval process before allowing expensive new cancer drugs. Who is making these decisions?
In each state, a group of people are charged with recommending how the funds available for Medicaid will be spent. In the state of Washington it’s the Health Technology Assessment Committee, a group of 11 physicians. They determine what medical procedures and devices will be used based on their cost and effectiveness. Because cost is a factor in their decisions, they’ve been criticized and compared to Britain’s NICE. It’s not surprising that the subject of “Death Panels” has come up here as well.
We’ve seen here how Medicaid, the government’s health care system for the poor, uses types of “Death Panels” to contain costs. Is there any “Death Panels” in our future? Although it’s been denied and derided, there’s evidence that there are. We’ll look at that next.