People fail to understand that nothing in life is free. All scarce resources must be rationed; if goods are not rationed by price, another mechanism must be used.
When patients abdicate the responsibility (including financial responsibility) of making health care decisions, third-parties will ultimately make those decisions for them. Britain’s NICE is one example –Canada’s shortage of PET scanners is another.
The thing that hit me a few months ago was that rationing via price is, from a theoretical standpoint, the most efficient means of rationing. People that have highly-valued skills are paid more and receive more generous insurance/compensation. People with lower-valued skills receive less compensation/benefits.
By rationing care without regard to income, we’re effectively saying that an individual’s contribution to society (as roughly measured by what the free market is willing to pay) doesn’t matter. An unskilled worker is the same as a brain surgeon.
The implication is that the sick who never had a chance to prove their worth or the poor who were unable to attend college are not valued in society. It sounds barbaric, and in a certain sense, it is.
But, the alternative isn’t much better. To legislate an entire portion of the economy such that the main measure of a patient’s ability to receive treatment is how long her/she waits is equally barbaric. At least letting the CEO pay for his cancer surgery will help him recover faster and return to work.
At the root, I think the argument is progress (treating the most able members of society and hoping that the others can find care at cheap clinics) versus community (treating everyone with the same level of respect). Denying one or the other creates an equally dismal outcome, but at least rationing based on price is more efficient, does not require a mountain of paperwork, and keeps those in positions of importance as healthy as possible.
Virginia:
I think you have hit on a fundamental difference between conservatives and liberals.
How to apportion a necessity that’s priced as a luxury.
Rationing on ability to pay is unacceptable from a traditional liberal’s perspective.
I think it also violates the traditional Christian way of dealing with such an important issue.
So, even Christian conservatives would seem to be uncomfortable with this rationing procedure.
Personally, i think a better way to ration would be on bang for the buck – the number of quality years of life the medical care can provide.
This is a more objective way, in my opinion, of rationing expensive care.
We all have x number of years, days, etc. of remaining quality of life, regardless of income.
And, importance, at least from a Christian perspective, is not based on one’s income.
Don Levit
Virginia: Why don’t you think about the rationing of medical services the same way you think about how other common societal obligations are treated. If you call the police or the fire department, 911 doesn’t prioritize your call based on your income. Certainly the founding documents of this country don’t distribute rights based on income. If you send your children to public school, you’d never accept teachers neglecting their needs in favor of a student whose parents earn more money then you. If you’re religious, those with higher incomes aren’t given first dibs for salvation, if anything the rich have to work harder for salvation. Talk all you want about how strictly economic criteria can provide efficient allocation of medical resources but a good case can be made that’s an essentially immoral view of medicine.
Education is rationed by price. Only the poor are trapped in dysfunctional schools run by government or stuck in lotteries or on waiting lists to get out. Those with more money move to better districts, buy after school programs for their kids, or go private.
The founding documents of this country don’t distribute rights based on income because the rights they delineate are negative rights–the right not to have government interfere in your life even if you are rich and have a lot that government wants. The Sixteenth Amendment was not a “founding” document.
I’m not arguing that it’s an essentially moral way to ration. The problems associated with scarcity of resources means that there’s no real moral solution either way.
I would argue that schools don’t educate equally based on income, that low-income kids regularly get the short end of the stick. Fire prevention is slightly more egalitarian, but it’s much easier to provide that on an equal basis than it is to provide health care. Same with trash pick-up and water and sewer.
I agree that looking at a person’s expected years of life is a better (slightly more moral) way to ration than simply saying, “This person makes more money,” but I don’t think it’s a pragmatic solution. (How do they determine years to live? Is it fair to let someone die that has the money to pay for more treatment even though years to live is low? And if we allow this person to pay for his treatment, are we being unfair to the others that don’t have the money by saying their life is less valuable via our system? Do we really measure the importance of life via a formula for number of years left?)
I realize that it’s a controversial opinion to take. And frankly, I don’t think that I would be very high up the ladder in a person-who-makes-the-most-money system. But, it’s the only system where I control my place in line. All of the other systems put control in the hands of the government or the hospital. At the end of the day, why is the NHS still forced to allow people the option of private treatment? It’s because those that have the money place the value on their own lives, which I would argue is the most moral position possible.
If they really and truly believed in the greatest good for the greatest number, rich people in Britain (and indeed all around the world) facing a terminal illness would call hospice and try to make the best of their days while giving the rest of their money to county hospitals. They don’t do that because it’s contrary to the survival instinct.
If we’re going to argue that it’s immoral to let people who have no money die because they lack money, we must also argue that it’s immoral to let people who might otherwise live die because they lack the correct spot in line. By allowing people to seek medical care in a private system, we grant credence of the fact that equality does not permeate all aspects of life.
Linda sez: “Only the poor are trapped in dysfunctional schools run by government”
I hate to tell you, but the technical and economic dominance of the United States following WW2 was created by students who graduated from what you call “dysfunctional” schools. If you look at the graduating classes of our most prestigious and competitive universities today, you’ll find that an overwhelming majority of their students are products of the “dysfunctional” public schools. Public education has been one this countries greatest distributors of equality of opportunity.
When discussing how to ration any material or service of value, particularly when we are speaking about the value of one’s life, one needs to consider aspects in addition to money.
While the Constitution is the basis of our laws, it is not the basis of my moral values.
For those, I look at values that have stood the test of time, and those are delineated way before 1776.
One can look at the Bible or other sacred texts, philosophers that we still speak of today, wisdom handed down for centuries, even millenia.
Those I place on a higher value than the Constitution.
If we come to the conclusion that health care is divvied up based on ability to pay, that is a very sad moral and ethical place to be.
We must honor the tension between me, myself, and I versus the community.
Rabbi Hillel stated this very well:
If I am not for myself, who will be for me?
If I am only for myself, who am I?
I would hardly call public schools “efficient.” Although given the way that outliers are ground up in the machinery, you’d almost think that it would be.
Regarding health care distribution, the only moral solution by Western standards involves at least two tiers. I think most of us would expect to see an egalitarian safety net, rationed at least in part according to quality years per unit cost. But it seems immoral to prevent individuals from spending their own money on care above the basic level, just as it seems immoral to force individuals to pay for care for others that goes beyond basic necessity, in other words that isn’t subject to the cost-effectiveness standard.
It seems to me the only questions are what to include in guaranteed, rationed, low-tier basic care; whether basic care should be means-tested (and at what level); and how to pay for it all.
I can think of nothing that would justify penalizing anyone for using their own money to purchase additional care. It’s not as though health care is an inelastic resource; if anything individual purchasers drive innovation the same as early adopters in other high-tech fields. Therefore, high-tier care should be available on a price-rationed basis.
Comparing today’s K-12 public schools with those of the 1950s is a nonstarter. There are vast differences in order, curriculum, teacher authority, teacher quality, content of the school day, reading materials, and class size. Those differences are reflected in time series test score data which show a sharp break in achievement in the 1960s.
I wasn’t talking about universities, but I see that I wasn’t specific. I talked about schools and kids and didn’t specifically stay K-12 public education.
Linda sez: “Comparing today’s K-12 public schools with those of the 1950s is a nonstarter”
Ah, the halcyon days of the 1950s, when blacks were forced to drink from separate water fountains in the south, when even exceptionally qualified women were denied admission to undergraduate and graduate schools, when if you had a developmentally or physically challenged child (I won’t repeat the term they were called then) they were denied education, when my own father had to get an MD because as a PhD in Organic Chemistry he couldn’t get a job because he Jewish quotas were filled at the drug and chemical companies. That’s what you want to return to? The time series you mentioned are bunk, because they don’t account for the opening of educational opportunities that also occurred in the 1960s.
People fail to understand that nothing in life is free. All scarce resources must be rationed; if goods are not rationed by price, another mechanism must be used.
When patients abdicate the responsibility (including financial responsibility) of making health care decisions, third-parties will ultimately make those decisions for them. Britain’s NICE is one example –Canada’s shortage of PET scanners is another.
The thing that hit me a few months ago was that rationing via price is, from a theoretical standpoint, the most efficient means of rationing. People that have highly-valued skills are paid more and receive more generous insurance/compensation. People with lower-valued skills receive less compensation/benefits.
By rationing care without regard to income, we’re effectively saying that an individual’s contribution to society (as roughly measured by what the free market is willing to pay) doesn’t matter. An unskilled worker is the same as a brain surgeon.
The implication is that the sick who never had a chance to prove their worth or the poor who were unable to attend college are not valued in society. It sounds barbaric, and in a certain sense, it is.
But, the alternative isn’t much better. To legislate an entire portion of the economy such that the main measure of a patient’s ability to receive treatment is how long her/she waits is equally barbaric. At least letting the CEO pay for his cancer surgery will help him recover faster and return to work.
At the root, I think the argument is progress (treating the most able members of society and hoping that the others can find care at cheap clinics) versus community (treating everyone with the same level of respect). Denying one or the other creates an equally dismal outcome, but at least rationing based on price is more efficient, does not require a mountain of paperwork, and keeps those in positions of importance as healthy as possible.
Virginia:
I think you have hit on a fundamental difference between conservatives and liberals.
How to apportion a necessity that’s priced as a luxury.
Rationing on ability to pay is unacceptable from a traditional liberal’s perspective.
I think it also violates the traditional Christian way of dealing with such an important issue.
So, even Christian conservatives would seem to be uncomfortable with this rationing procedure.
Personally, i think a better way to ration would be on bang for the buck – the number of quality years of life the medical care can provide.
This is a more objective way, in my opinion, of rationing expensive care.
We all have x number of years, days, etc. of remaining quality of life, regardless of income.
And, importance, at least from a Christian perspective, is not based on one’s income.
Don Levit
Virginia: Why don’t you think about the rationing of medical services the same way you think about how other common societal obligations are treated. If you call the police or the fire department, 911 doesn’t prioritize your call based on your income. Certainly the founding documents of this country don’t distribute rights based on income. If you send your children to public school, you’d never accept teachers neglecting their needs in favor of a student whose parents earn more money then you. If you’re religious, those with higher incomes aren’t given first dibs for salvation, if anything the rich have to work harder for salvation. Talk all you want about how strictly economic criteria can provide efficient allocation of medical resources but a good case can be made that’s an essentially immoral view of medicine.
artk,
Education is rationed by price. Only the poor are trapped in dysfunctional schools run by government or stuck in lotteries or on waiting lists to get out. Those with more money move to better districts, buy after school programs for their kids, or go private.
The founding documents of this country don’t distribute rights based on income because the rights they delineate are negative rights–the right not to have government interfere in your life even if you are rich and have a lot that government wants. The Sixteenth Amendment was not a “founding” document.
I’m not arguing that it’s an essentially moral way to ration. The problems associated with scarcity of resources means that there’s no real moral solution either way.
I would argue that schools don’t educate equally based on income, that low-income kids regularly get the short end of the stick. Fire prevention is slightly more egalitarian, but it’s much easier to provide that on an equal basis than it is to provide health care. Same with trash pick-up and water and sewer.
I agree that looking at a person’s expected years of life is a better (slightly more moral) way to ration than simply saying, “This person makes more money,” but I don’t think it’s a pragmatic solution. (How do they determine years to live? Is it fair to let someone die that has the money to pay for more treatment even though years to live is low? And if we allow this person to pay for his treatment, are we being unfair to the others that don’t have the money by saying their life is less valuable via our system? Do we really measure the importance of life via a formula for number of years left?)
I realize that it’s a controversial opinion to take. And frankly, I don’t think that I would be very high up the ladder in a person-who-makes-the-most-money system. But, it’s the only system where I control my place in line. All of the other systems put control in the hands of the government or the hospital. At the end of the day, why is the NHS still forced to allow people the option of private treatment? It’s because those that have the money place the value on their own lives, which I would argue is the most moral position possible.
If they really and truly believed in the greatest good for the greatest number, rich people in Britain (and indeed all around the world) facing a terminal illness would call hospice and try to make the best of their days while giving the rest of their money to county hospitals. They don’t do that because it’s contrary to the survival instinct.
If we’re going to argue that it’s immoral to let people who have no money die because they lack money, we must also argue that it’s immoral to let people who might otherwise live die because they lack the correct spot in line. By allowing people to seek medical care in a private system, we grant credence of the fact that equality does not permeate all aspects of life.
Linda sez: “Only the poor are trapped in dysfunctional schools run by government”
I hate to tell you, but the technical and economic dominance of the United States following WW2 was created by students who graduated from what you call “dysfunctional” schools. If you look at the graduating classes of our most prestigious and competitive universities today, you’ll find that an overwhelming majority of their students are products of the “dysfunctional” public schools. Public education has been one this countries greatest distributors of equality of opportunity.
When discussing how to ration any material or service of value, particularly when we are speaking about the value of one’s life, one needs to consider aspects in addition to money.
While the Constitution is the basis of our laws, it is not the basis of my moral values.
For those, I look at values that have stood the test of time, and those are delineated way before 1776.
One can look at the Bible or other sacred texts, philosophers that we still speak of today, wisdom handed down for centuries, even millenia.
Those I place on a higher value than the Constitution.
If we come to the conclusion that health care is divvied up based on ability to pay, that is a very sad moral and ethical place to be.
We must honor the tension between me, myself, and I versus the community.
Rabbi Hillel stated this very well:
If I am not for myself, who will be for me?
If I am only for myself, who am I?
I would hardly call public schools “efficient.” Although given the way that outliers are ground up in the machinery, you’d almost think that it would be.
Regarding health care distribution, the only moral solution by Western standards involves at least two tiers. I think most of us would expect to see an egalitarian safety net, rationed at least in part according to quality years per unit cost. But it seems immoral to prevent individuals from spending their own money on care above the basic level, just as it seems immoral to force individuals to pay for care for others that goes beyond basic necessity, in other words that isn’t subject to the cost-effectiveness standard.
It seems to me the only questions are what to include in guaranteed, rationed, low-tier basic care; whether basic care should be means-tested (and at what level); and how to pay for it all.
I can think of nothing that would justify penalizing anyone for using their own money to purchase additional care. It’s not as though health care is an inelastic resource; if anything individual purchasers drive innovation the same as early adopters in other high-tech fields. Therefore, high-tier care should be available on a price-rationed basis.
Comparing today’s K-12 public schools with those of the 1950s is a nonstarter. There are vast differences in order, curriculum, teacher authority, teacher quality, content of the school day, reading materials, and class size. Those differences are reflected in time series test score data which show a sharp break in achievement in the 1960s.
I wasn’t talking about universities, but I see that I wasn’t specific. I talked about schools and kids and didn’t specifically stay K-12 public education.
Linda sez: “Comparing today’s K-12 public schools with those of the 1950s is a nonstarter”
Ah, the halcyon days of the 1950s, when blacks were forced to drink from separate water fountains in the south, when even exceptionally qualified women were denied admission to undergraduate and graduate schools, when if you had a developmentally or physically challenged child (I won’t repeat the term they were called then) they were denied education, when my own father had to get an MD because as a PhD in Organic Chemistry he couldn’t get a job because he Jewish quotas were filled at the drug and chemical companies. That’s what you want to return to? The time series you mentioned are bunk, because they don’t account for the opening of educational opportunities that also occurred in the 1960s.