Tuesday, December 14, 2010

Right Where The Rubber Meets the Road

In the healthcare debate, here's where the rubber is going to meet the road. Right here:

Randall Shepherd, a 36-year-old father of three who needs a new heart after childhood battles with rheumatic fever, is one of 98 Arizonans no longer eligible for state-paid transplants after Governor Jan Brewer and the Legislature eliminated funding.

Shepherd, a plumber from Mesa who no longer can work, said he was next on the list to receive a heart of his size and blood type when the transplant program was eliminated Oct. 1, cutting him off from the $600,000 procedure. Now, “I wouldn’t even be notified,” he said in a telephone interview, his breathing labored.

The Republican governor’s elimination of transplants to save $800,000 toward a $3 billion budget deficit makes Arizona the only state to do so in the past two years, according to a report from the Henry J. Kaiser Family Foundation, a nonprofit health-care researcher in Menlo Park, California.

I don't pretend to have the answers here. But I know the question: are we going to let sick unfortunate Americans die?


  1. **are we going to let sick unfortunate Americans die?**

    We always have before. We can't provide everything for everybody -- it's not physically possible. Many states do not fund transplants at all under Medicaid.

    The real question is, where do you draw the cost/benefit lines for state-paid health care?

  2. C'mon man, same thing. Where's your sense of poetic license?

    I wasn't trying to wave the bloody shirt. Really I wasn't. :-)

    I hope when we draw the lines, we draw then so that people who have kids and are still young get expensive operations if they'll prolong lives substantially. I'd be a lot more Ok with not funding this guy's care if he was, say, 66 or 76. Not that age is the only rrlevant factor of course.

  3. My poetic license was suspended for multiple convictions of failure to hyperbolize, unauthorized turns against partisan mythologies, and (worst of all!) blogging under the influence of reality.

    (Did you know that in that last a BAC under 0.08% counts against you? They take the blood samples with fingernails and fangs ... )

    It's easy to find heart-tugging cases, but in the real world it's all a tradeoff among multiple priorities utilizing limited resources. It's not just the $600K cost of the operation for this poor guy, but also the $50K/yr or so upkeep in testing and monitoring and immuno-supressant drugs that under average post-op life expectancy will easily double that tab. All versus the other possible uses of those limited Medicaid resources.

    Frankly, the transplant center knows they could do the operation much cheaper than the quoted "retail price" if the heart is available -- but they also have to prioritize. Yet somehow it's the state (the public) that gets all the blame thrown at it for not coughing up the cash.

    If poor Mr. Shephard were 66 or 76 we wouldn't even be having this discussion as far as this particular case goes. That's past the usual cutoff age for heart transplants.

  4. Oh, and just to point out what was obvious to ANYONE PAYING ATTENTION during the ObamaCare cramdown, we are guaranteed to see more and worse when it comes to Medicaid. Fully half or more of the "additional coverage" touted for ObamaCare comes from radically expanding Medicaid, which of course is an unfunded mandate on the state's tab. And the states don't have the money.

    Also, the states are now hidebound by the rules of the stimulus and ObamaCare, which says they CAN'T reduce their current MCD income eligibility levels. That leaves the only slack in reducing services covered. Even before the MCD expansion kicks in, CMMS has projected that state MCD expenses will increase by 40% or so from 2010 to 2011.

    No matter how long and often you point out to people that there ain't no such thing as a free lunch, they still believe someone else will pick up the tab. To echo Margaret Thatcher, we are running out of other people's money, and all the good intentions in the world won't change that.

  5. I don't discount anything you say about medicare, medicaid, or HCR in general, You seem, as usually very well informed.

    Let's presume for the sake of argument that Obamacare is going to either collapse under the weight of its crappiness or require substantial revisions and correction to be even remotely practiceable. And let's further presume that which one of those it is doesn't matter.

    Do you have any thoughts on a short list of decent positive ideas to manage healthcare costs while providing decent access? Do you think we're really better served with private provision, or is it unrealistic due to the complexity of medicine?

    What I would like to see is some sort of guarantee of basic care for all, along the lines of a medicare for all Then we could either have supplementary insurance for the above basic level, or a series of additional levels available to all at a sliding cost scale.

    So for example, when you become an adult, you would choose whether you wanted bare bones, fairly comprehensive, or cadlillac. And you could climb that scale as you aged, but the later you decided to scale up, the more your premium would be.

  6. Let's presume for the sake of argument that Obamacare is going to either collapse under the weight of its crappiness or require substantial revisions and correction to be even remotely practiceable.

    No presumption needed. We're already watching it happen. And it will get progressively worse.

    Short list? I'm sure it was all gone over quite copiously in the last few years. As other nations keep discovering, you don't get rid of the problem by nationalizing it, that just politicizes the rationing and guarantees bigger shortages and eventual stagnation. If I had to pick just ONE item that would be key, it would be uncoupling health insurance from employment through changes in the tax code. If I could add another, it would be to drop the interstate barriers to policy sales. And the trifecta would be the establishment of a "minimum basic coverage" standard, such as seen in Switzerland, for example. Or skip all of the above and start DOUBLING or more the number of doctors we train.

    Some forms of these things are in ObamaCare, BTW, but not in terribly useful form, mostly mangled up to serve special interests while paying lip service to the concepts.

    What I would like to see is some sort of guarantee of basic care for all, along the lines of a medicare for all

    We have that, you just have to be broke to get it. It's called Medicaid, and that's where this thread started. Which leads directly back to politicization. As any doctor (or clinic manager) can tell you, both MCD and MCR are highly subsidized, not just by younger wage-earners and taxpayers but by massive cost-shifting onto the private sector -- where will those subsidies come from if everyone has MCD/MCR?

    No easy answers. No magic bullet. As I've said over and over, we spend so much as a society on health care because we're willing to and can afford to. We can no doubt capture some efficiencies for one-time savings, but the idea that excess cost growth in health care can be stopped by changing sytemic delivery modes is ignorant, as other nations are proving.

    Not that we shouldn't try to capture some of those savings and get more bang for our buck ... but the basic problem will still remain. We can't do everything for everyone.