Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
In his recent post on Slate, the intrepid Jacob Weisberg eagerly plays the death card in order to excoriate Republican presidential nominees for their incoherent and cowardly opposition to ObamaCare in the latest primary debate. The hypothetical that we have to address is this: what should be done with a person without insurance who suffers catastrophic illness, which requires six months of intensive care? Should that person be allowed to die or should that person be supplied that care at public expense under, of course, ObamaCare?
One telling illustration about this example is that Weisberg does not tell us whether the individual who receives this care lives or dies when the treatment is over. If we assume the latter, the initial question is whether intensive care at, say, $10,000 to $20,000 per day represents the best use of social resources. A bit of simple arithmetic says that society has spent $1.83 million to $3.66 million on a venture that may well have kept this person alive in a comatose state or have subjected him to repeated invasive treatments when hospice care may well have been preferable. Alternatively, that person could have lived, but we do not know in what kind of state or how much money it will take to sustain him. In this instance, we might derive somewhat greater benefits, but only at a far greater cost.
The only alternative that is not covered by Weisberg's hypothetical is a case in which intervention is really cost effective: the use of a single day in the intensive care unit that results in keeping a person who suffers from a sudden injury alive so that he or she can return to a normal life thereafter. The hard question therefore is why is it so apparent to Weisberg or anyone else, that letting a grievously ill person die is the wrong alternative for a society that is determined to make its health care dollars go as far as they want. Weisberg never addresses this question in a coherent fashion because he is innocent of the notion that high levels of health care expenditures on one individual could exhaust resources that could have enabled many other individuals to survive. It is just irresponsible to ignore the hard question of scarcity in asking how to set social priorities.
The point has to be put in larger perspective. The question here is not whether people who lack money should receive health care free of charge. Of course they should. But the issue is which people should receive that care, and why? All of those hard issues are swept under the rug by acting as though nothing else will change if huge levels of resources are devoted to the first person that is carted into the emergency room. So what kind of institutional arrangements can deal with this issue?
One system that has already shown its defects is the 1986 EMTALA, or the Emergency Medical Treatment and Labor Act, signed by President Reagan. That legislation requires hospitals at their own expense to take in patients that need emergency care or are in active labor, and treat them until stabilized. Weisberg thinks that this statute is flawed, because these costs are not absorbed by hospitals but are passed on to consumers, employers and the government.
In fact, the economics of EMTALA are far more complex. In some instances, these costs cannot be passed on, so the hospitals that used to run emergency rooms shut them down, which put more people in peril. Nor is the issue of whom absorbs the costs the only one that has to be faced. There is the greater defect that EMTALA requires huge expenditures to be made for the wrong people, so that comatose individuals with little hope or revival, or chronic abusers get first call on social resources, which in turn are no longer available to others. The simple point about EMTALA is that in its effort to solve the access problem, it aggravates the moral hazard issue, by encouraging reckless or dangerous behavior in individuals who know that they can have care as of right. The result has not been pretty. Many ERs have shut down because their hospitals cannot meet the costs.
The provisions under ObamaCare will do nothing to address these difficulties. The premiums that are paid under the mandate may prove to be insufficient to cover the whole cost of these operations. The treatments in question may well be given to the wrong people for the wrong reason. The socialization process that does not work under EMTALA will not work under ObamaCare.
So what then is the solution? Here it is worth while taking a bit of historical perspective. The problem of taking care of very sick people did not arise in 1986. It was with us as a nation throughout our history. In the early days, there were very few people who were just left callously to die on streets. Charitable hospitals did open up their doors to supply extensive care even in the days before government reimbursement and tax deductions.
The key to their success was that they had the right to exclude people. That right was important not because they wanted certain patients to die, but because it allowed them to prioritize their care in the manner that they saw fit. It allowed them, in a word, to decide that hopeless cases and chronic abusers do not receive the same amount of care as others, and perhaps no care at all. Once they knew that they could use their resources as they saw fit, they could more effectively raise funds from private individuals who did not have to fear government appropriation of moneys through unwise programs. No one says that this alternative is perfect. But the greater the number of independent charities, the less likely it is that the failure of mission or purpose of any one of them will bring down the system.
Jacob Weisberg writes as though he, a compassionate person, can put these silly Republicans to shame. I have no desire to defend their statements, for they don’t seem any more sophisticated than he is. But it is worth noting that his systematic ignorance of how to deal with scarce resources in end of life situations could have tragic consequences. Put his preferred regime into place and there will be more needless deaths than in a voluntary regime that relies on private compassion and good sense to achieve a result that no set of government mandated programs could hope to match.
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Comments :
Sep '10
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
For 50 years the country has been operating under a prepaid medical system which has a third party paying the bulk of the cost of medical care. This system also contains an insurance component. Since the system results in high administrative cost, high fraud cost and high legal cost and does not provide effective cost containment incentives it has resulted in spiraling medical costs. Until payment for expected routine medical care and unexpected catastrophic emergency medical care are separated little progress will be made in this area. Health Savings Accounts is step in the right direction, but generally only receives minimal support. As you pointed out there is no perfect answer to the problem presented.
Feb '11
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
Richard, your solution sounds eminently reasonable; and I know you said this system is not perfect, none are, so I can understand if it has no response to these questions, but I will ask them anyway:
1) Does this solution allow for any appropriation of government funds or tax deductions for hospitals that can't get enough donations, or would this increase the moral hazard again?
2) If a charity hospital (the only one in the rural area) chose to discriminate against an indigent minority what recourse does he have, being that there is no other hospital in the general vicinity. Is this analogous to the boat owner who has the right to use a stranger's dock in a storm?
Jun '10
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
There is no perfect answer, Liberal Jim, but Richard has done a marvelous job of laying out the issues. In general, society cannot provide the best for the poorest without re-defining what is best and lowering the overall quality of available care for everyone. That is ridiculous. Your listing of some of the underlying reasons for the dramatic and constant increase in the cost of health care (which necessarily increases the cost of insurance) was spot on. For many senior citizens, visiting doctors offices is a substitute for a social life because medicare and its supplements pay for everything. Under Obamacare the same will happen. The abuse of overuse of the healthcare sysytem will bankrupt the whole thing in a decade at most. We must void this law.
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
Bravo Richard, and concurrence w/ Liberal Jim. This relates to Blitzer's debate question, about the 30 year old who opted not to get insurance and suddenly needs intensive care -- the right question is not whether he gets care, but who pays, and the proper answer, one lived by friends who have made similar choices and then experienced medical crises -- is who pays? And the answer, assuming the 30 year old lives, is he does, and he will work out a payment plan for the (ridiculously expensive, see Liberal Jim's observation) care which he received.
The other rich irony is that while universal coverage is sold on the admirable wish and premise that everyone should have high end medical care, the reality of cost constraints lead such bureaucracies to then systematically deny those things we would consider routine - whether because a sight-saving medicine is too expensive, a patient is "too old" for a new hip, and woman is "too young" for mammography, etc.. If one wants to be "fair" (defined as providing only identical treatments universally) above all, it is worth remembering that those desperately poor countries where has been no medical care for anyone qualify in spades.
Sep '11
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
John Mackey's editorial in the WSJ over a year ago nailed it. We are so divorced from the cost of medical care that neither the doctor nor the patient even knows what a procedure costs. HSA's with catastrophic coverage are the only viable solution proposed. It reintroduces some market discipline to choices about medical care and it returns some control to the individual patient. Weisberg structured his question the way he did because he knew that feckless individuals already routinely receive true emergency care without Obamacare. My own ER experiences have reinforced the idea that there is a lot of NON emergent care being provided in ERs because patients know ERs have to provide it and it costs welfare patients nothing. A Texas hospital found that 9 patients had cost them 2.5 million in ER costs over a 2 year period. Note: if you are really sick you get admitted to the hospital and it is no longer an ER cost. Prima facie, these people weren't very sick because they kept coming back and weren't admitted. If people benefit financially from NOT using medical care, they will make better choices.
Jun '10
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
Dr. C. Everett Koop summed up the problem: "Americans think that death is an option."
Aug '10
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
Why don't we have the government provide us all with loving friends or family who will make these choices for us ?
Guess that they can't do that either. So, how about a caring God ? Well, that's done, but he thankfully put some limits in place, like how long we get to live, etc.
No, the etc. doesn't include letting the government role play.
Edited on Sep 16, 2011 at 11:22amJun '10
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
We are completely divorced fromt he cost of medical care in America. And not just cost in terms of money, but in the loss of human dignity as invasive and pointless procedures are performed on the elderly in their last weeks of life. Heroic (and costly) efforts to prolong a life for a short amount of time, often to be spent in a hospital bed with absolutely no patent awareness of his surroundings, are simply cruel and inhuman. We need to work toward death with dignity. We need to stop using the term "death panel" when we have the necessary conversation about what end-of-life measures are wise and compatible with our Judeo-Christian tradition.
May '10
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
Calling George Savage. We need his view on EMTALA and how it actually plays out in his ER practice.
In my Health Law class cases, it appeared that this was not really as big a deal as is generally presented (in terms of actual marginal cost increases; under the accounting system for reimbursements, more problematical. See "hammer, Pentagon, $900" for further details on that issue).
Added: Let me note that the most popular response by many ERs is not to shut down, but to try to "turf" the problem cases off to other hospitals. Michelle Obama's Chicago employer was somewhat famous for that.
Edited on Sep 16, 2011 at 12:32pmAug '10
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
Time to stop the golden kisses, I tell my kids that I have rented a big truck and one day in the future it's going to come around the corner as I am crossing a street and flatten me like a pancake, no hospital bills, they can cremate me right there in the street.
Jan '11
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
Well, what about taxpayers paying for the care, and if and when the care is finished, the beneficiary does some sort of work for the taxpayers to pay something back - the effort and duration to be commensurate with ability. Sure, it's only a good faith effort, but it does present the person with a way to maintain self respect, and the taxpayer to satisfy the social compact responsibility. It seems to me that any other resolution confirms that there really is such a thing as a free lunch.
Of course, that would also require that we resurrect the long lost concept of self respect.
May '10
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
This is only tangentially related to Professor Epstein's post, but the Richard Epstein v. Lawrence Tribe debate on the constitutionality of ObamaCare, which took place last night at the Manhattan Institute, has now been posted on that entity's website:
http://www.manhattan-institute.org/video/index.htm?c=091511_CLP
I heard about it too late to secure a reservation to see the debate in person on 7 W. 43rd St., but this video is a pretty good consolation prize.
Mar '11
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
I usually refrain from commenting on American health care but I have strong feelings, based on experience, about insurance and its amazing propensity for creating perverse incentives and unintended consequences.
The alternative to 'death panels' is individual responsibility and the the possibility, that the fit healthy 30 year old who chooses not to spend a lot of money on health insurance might die unnecessarily because of his choice, would create a market for an austere insurance which covered only catastrophes. If government did not interfere, medical 'catastrophe only' insurance would create the least perverse incentives and thus limit the growth of health costs and encourage innovation in health care delivery.
Aug '10
Re: Playing the Death Card in Health Care Debates: A Response to Jacob Weisberg
First of all, there are other institutions besides the Individual and the Government. Just because the latter declines to give the former free medical care doesn't mean no one else will contribute.
That said, why can't the government establish a program of "post-insurance"? If someone with no insurance required medical care he couldn't pay for, and the government picked up the tab, this could become a debt that would be gradually repaid through a significantly higher future tax rate. This would put collection under the normal income tax enforcement mechanism. In some cases, the person would eventually pay off the debt, in others the debt would never be fully repaid, but the government would get a substantial amount back from the very people it gave the money to, and it wouldn't destroy the incentive for people to buy insurance before needing medical care.