The Most Difficult Decision

As the healthcare debate appears to have stalled in Congress, perhaps we should take note that health care is a limited resource. How to best divide this resource, in terms of how to define what is covered and what is not, has yet to be adequately debated.

A clever Perspective in the New England Journal of Medicine last month verbalized one of the most neglected issues in our current health care debate. How can America reconcile the conflict between covering more people versus covering more health services given a fixed amount of resources devoted to the health sector? The authors provide a simple comparison of the costs of insuring more Americans based on the cost of health insurance premiums. They looked at the cost of premiums ranging from 10th percentile ($2,800)), median ($4,200), and 90th percentile ($6,000) and calculated that to insure an additional 50 million Americans the nation would need to spend an additional $140, $210, or $300 billion annually, respectively.

Looking at the problem from another angle, the authors provide estimates on the average number of quality-adjusted life-years (QALYs) gained from certain medical interventions. Given the same fixed budget of $180 billion, the United States could provide left-ventricular assist devices for heart failure patients and thereby gain fewer than 360,000 QALYs. Alternatively, the nation could provide HIV medications and receive over 1.8 million QALYs. Currently, our society chooses among these choices based on financial factors. If you can afford it, you can purchase whatever health care technology will pay for. If you can’t, even inexpensive technology is out of a patient’s reach.

The authors go on to remind us of the Oregon Health Plan, where a commission of patients and doctors sought precisely to determine the relative value of various health care interventions. The goal was to change the implicit rationing our current health care system provides via the patient’s financial situation with that of explicit rationing via cost effectiveness and participatory democracy. However, the Oregon Health Plan has not been very successful at rationing care or saving costs. This is largely a factor of politicians being unwilling to implement deep cuts in services to their constituents.

Commentary
Our current health care debate has focused on expanding coverage to the uninsured, providing subsidies to help the uninsured purchase insurance, and fixing business practices which allow health insurers to avoid risky patients and abandon sick ones. What the health reform debate has missed has been a genuine discussion about the scope of health insurance, that is, what services should and should not be covered. Other than abortion services, which are only mentioned because of the ideological fervor separating the political parties over that issue, and mammography, which only became an issue when the USPSTF altered their recommendations, minimal energy has been devoted to determining which health care services our society values over others.

This article reminds us that the most difficult decision is adjudicating the battle for health care resources between the uninsured and the overinsured. Our political process makes it possible for specific interest groups to politically guarantee access to certain treatments or therapies. By requiring certain benefits be covered, the cost of insurance for everyone goes up. The more services required, the costlier it becomes.

The health reform bills under debate defer the definition of “minimal credible coverage” to administrators within the Department of Health and Human Services. First, our society must come to grips with the inevitable truth that health care is a limited resource and decisions must be made regarding how much, to whom, and by what means to distribute this resource. We cannot realistically cover all things for all people. We should not cover all things for some people. The first priority of our healthcare system is universality. With that as a goal, difficult decisions about where to draw the line on benefits coverage must be made in such a meaningful way that funds allocated for health can cover some things for all people.
NEJM. 2010. 362; 2: 95-97.

by
Cedric K. Dark, MD, MPH