Health Care: Cost effective policy.

This fascinating article appeared in the NYT recently. It discussed the British program called NICE which determines which treatments the National Health Service will cover based on calculations of cost effectiveness. There are many issues brought up that are worth discussion.

First I applaud the efforts of the British government to negotiate prices. While that was not the intended goal of NICE drug companies have increasingly eased prices so that their treatments are covered. This is fantastic. If medicare and medicaid had the power to negotiate prices I'm sure we would save tax payers billions of dollars. Those services represent such a huge share of the market that their power would be profound. And drug prices are so erroneous and exploitive, something has got to be done. Reading this made me wonder why prices aren't tied to efficacy in some way. That kind of price model might in the very least give the drug companies a leg to stand on when they try to defend their fleecing of the dying. I can't imagine this country having the balls to play this kind of hard ball. Even the best solutions put forward this election season for solving the health care crisis are full of consessions to industry. In my optimism I view them as step 1 on a road left.

The ethics of this program are worth discussing as well. If a National budget and health system risks ruin (as I believe ours does) then maximizing cost-benefit for health care may be the only ethical way to insure that citizens are able to rely on a basic standard of care. But deciding that that level of care is going to be less than the highest that our technologies and skills are capable of is a hard pill to swallow for anyone. I don't know if the British ever claim to have the best health care in the world but I know the US certainly does. Despite the fact that we don't. We are capable of delivering great care to the relatively few rich and well insured. But our health outcomes as a nation are embarrassingly behind the rest of the world. Pragmatically, it is imparative that we accept that so far we have failed; that 'slowing progress' which industry threatens may be a necessary concession to save the masses and wallets of all.

Patients in Britain who are on the losing end of NICE, like the patient with kidney cancer, might be best served in the future by a two tier system. This is the system that I ultimately believe the US will be forced to adopt, as it is the only one that I can imaging being both financially tenable and still leaves a place for our precious free market. In this system you have universal health care for everyone that assures an 'adequate' level of health care, and you have a private optional insurance system that people can buy to pick up where universal care leaves off. Because a standard level of care is already maintained this could really work on an old school insurance style model, and possibly serve consumers much better. Fewer people would make claims and things like doctor choice and elective and heroic procedures could more easily be covered. As a future physician I cannot see this as an ethically perfect solution. I believe a physicians ethical obligation is always to provide the highest standard of care they are able to each of their patients. The British NICE deserves a lot of credit for its dedication to egalitarianism.

"After consulting a citizens group, the institute decided that the nation should spend the same amount saving or improving the life of a 75-year-old smoker as it would a 5-year-old." When it comes to life I am definitely a quality over quantity kind of girl. It really bothers me that improving a life is subject to the same cost effective analysis that extending a life is. If a drug fits their criteria of extending a life for 6 months but has horrible and debilitating side effects this too should be considered in the financial analysis. And if quality of life is improved, as for the MS patient mentioned in the article, I find it extremely unsettling to deny the treatment. As policy this gets dicey. Ideally this is the sort of decision a patient should be allowed to weigh in on.

The reality of our situation, in the midst of a war and a financial crisis, is that we are going to be forced as a society to make some tough decisions. Should smokers pay more for health care? Should fat people? But all of it involves making a decision that I'm still not sure we as a nation have made. Barack Obama made me swoon in the second debate when he said, simply and directly, that he thought "[health care] should be a right." Making and embracing this idea emphatically requires that we come up with a quality level of care that is freely available to everyone. Realistically we must also realize it can't be perfect.

Obama's Citizenship Questioned

Sorry It's been a little while since I've written anything in a little while. I'm afraid I've been experiencing something that scares me. I didn't realize how bad it was until I read this article in the Wall Street Journal online. To summarize: people are challenging Obama's citizenship on the grounds his father was a British citizen and the court has never officially established what it means to be a natural born citizen. Many of these suits were filed across the country and the only person to take the suit seriously is dear Justice Thomas. (When I hear his name I always think of Justice Marshall's comment "a black snake is still a snake".) The case now needs the approval of four justices to be heard before the court. My reaction to this farce is hard to express in written form but it went something like this: "OH MY GOD CLARENCE THOMAS IS THE WORST PERSON IN THE WORLD" followed closely by post traumatic flashbacks to 2000. The stolen election flashed before my eyes and hyperventilating and shouting at and with my husband and shouting phone calls to my parents (who annoyingly failed to take it seriously). A friend of mine dug up some more info, I'm not sure from where, and discovered the punch line. Apparently John McCain was not, in fact, born on us soil. His family was stationed abroad and congress quietly passed a law declaring him a 'natural born citizen' before he embarked on his presidential run.

So most people did not find this quite as sensational as I did. This morning I found myself wondering why. Then I realized the problem: I've been happy lately. Politically speaking. Obama has more or less been doing a sensational job. I have not yet been disappointed. My complaints (among them a discomfort and skepticism regarding his appointment of Hillary) are quite minor. I have an open mind and a trust that he knows better than me and I am ready to be proved wrong. So when I stumbled across this citizenship fiasco all this rage and delicious frustration that I just haven't been able to feel lately suddenly felt free.

I realized I don't know how to play this person I now find myself being. For so long I defined myself as a radical leftist dissident. And at the same time I constantly felt frustrated with what I saw as a lack of pragmatism and political savvy on the left which I saw as constantly setting us back. So I was the idealist who worked for Gore instead of Nader and didn't really feel at home in either camp. In short there was always something really substantial to get mad at. Now I'm irked by the obsession about the Obama dog. It's kind of trippy.

I must make one thing clear: I'm not complaining. I am eager to adapt to this new world order. I'm just not sure I know how to do it. (Did you notice OJ is going to jail? It's like the world has been turned upside down!)