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January 24, 2004

And you thought H-BD was controversial.

Reading this post by Godless on healthcare fired off some neurons in my brain about a proposal made in 1984 by Governor Richard Lamm of Colorado - the elderly have a duty to die.

I remember watching Lamm on 60 Minutes as he made his case and I followed with interest the firestorm that ensued afterwards. He spoke an unacknolwdged truth that people just didn't want to hear, much like the issues surrounding Human Bio-Diversity.

Here is an excerpt from an interview:

Lamm advocates age-based rationing of healthcare as a way to curb costs, because he views the aging of the population as the principal cause for those increased costs. He also wants an end to any more age-based benefit programs. Says Lamm, "Of course we have more of a duty to a 10-year-old than to a 60-year-old. Common sense says we should reserve the expensive medicines and technology for those who have the chance of a longer life."

He set out a scenario of future intergenerational warfare, where the young and middle-aged, would be paying for an extensive, and expensive, health care regime for the elderly, because the elderly had more political clout, while at the same time increasing numbers of children couldn't even get immunizations.

The macroeconomic conditions that precipitated Lamm's comments back in 1984 are still existent today. As noted in Trickster's post at tactitus health care now accounts for 14.1% of GDP and last year's health care inflation grew at 7%. How long can health care costs grow faster than the economy as a whole before some type of rationing will have to take place?

Lamm was primarily concerned with Medicare:

He worries, “There is something terribly inappropriate about a society which does not even provide basic health care to millions of people and yet amends its Medicare regulations to pay for heart transplants, a number of which go to the wealthy elderly.”

Lamm's concern was with the actuarial soundness of Medicare:

This year, Social Security and Medicare will account for 6.5 percent of gross domestic product (GDP). By 2030, those programs will grow to 11.0 percent of GDP. Moreover, the number of beneficiaries will grow much faster than the number of workers paying taxes to support those programs. The ratio of covered workers to beneficiaries will drop from about 3.4 this year to about 2.3 by 2030.

We must live in tamer times for I'm not coming across reform proposals that are as radical as Lamm's. But then again the growing prominence of the right-to-die movement may be the slippery slope towards utilitarian life & death decisions that critics fear. For that is what Lamm advocated:

Lamm suggests that healthcare rationing be reconfigured on a utilitarian basis: in such a way that the greatest possible number of people receives the greatest possible amount of healthcare. Lamm advocates a healthcare rationing system that would provide the greatest good for the greatest number; he wants to “buy the most health care for our society.”

Of course, who makes those utilitarian decisions is left unmentioned. The fears are that bureaucrats or carved in stone regulations will be cutting short people's lives. But then again is that necessarily worse than HMO administrators denying treatment?

What I think bothered Lamm the most was the HUGELY expensive treatments for the critically ill patients that only extended their lives for a period of months. There was no price rationing mechanism when analyzed with respect to the Hippocratic Oath. The immediate concern of the physician is the patient before him and it's very difficult to assign value to the hundred thousand dollars expended on extending a 75 year old patient's life for 2 months and then comparing the value that could be gained by denying such care and instead making the funding available to school children who are uninsured.

A major benefit of free-market health care is the vitality of the system and the diversity of choice available to patients and practitioners. Because Medicare is not based on a free-market model there is no checking mechanism to insure an overall societal good. Does the size of a voting constituency necessarily indicate the best decision? How come the elderly insure their selfish well-being via benefits to Medicare but allow some of their collective grandchildren to go uninsured?

What is to be done? The system is not firing on all cylinders for it cannot be efficient to have children be ill, and possibly have life-altering consequences from those illnesses that will affect them for the remainder of their lives, and impact on their economic and personal contributions to society, while at the same time devoting resources to a dying person.

If the answer is to find utilitarian value in these life & death decisions then this will play towards centralized decisionmaking and regulations which are inherent characteristics of socialized medicine (Medicare.)

Of course, the market could solve the problem of intergenerational health care issues by prohibiting intergenerational wealth transfer via taxation. If people had to pay for their own health care premiums and they could chose different policies based on life-time medical cost caps then the market could most efficiently arbitrate what may come to be a future problem.

It may soon come to be that life extension technologies will become so expensive that the net assets of a patient may not be sufficient to cover the cost of treatment and the tempation for drawing more from society than one has contributed will be an irresistanble impulse, for one's life itself will be at stake. The sharing of risk via insurance will become moot for every person will incur this cost rather than a statistical sample from the population, thus voiding the risk amortization principle.

I thought I'd offer this topic up for discussion because I wanted an excuse to practice posting (so I ask your forebearance if there are formatting errors.) I'm not usually concerned with health policy - my main interests are energy policy, space policy, demography and foreign policy. I hope to be posting more in the future.

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