My recent piece on Zeke Emanuel’s desire to die at age 75 generated a lot of comments, most positive but some equally negative. One from a Jennifer Clowney deserves an in-depth response. She wrote:
I can understand how some might respond negatively, at least in a knee jerk fashion, to some of the things [Emanuel] is saying. But what specifically do you dislike about what he’s saying here? We DO spend too much money on the elderly and prolonging the dying process. This is a simple fact. We only have so much money, resources, time and effort to put into the health care system. Unfortunately, there is not an infinite supply of anything. So that is a real issue. Quality of life DOES decline in advanced years, this is a FACT. Infirmed elderly DO place a huge burden on their families and society. This is a FA CT. All Emmanuel is advocating is that people take matters into their own hands for THEMSELVES. Think about how you want to approach the end of your life. Think about what you want to put your children through. Think about whether spending the last 2 weeks of your life in the ICU, on ventilators and pressors and dialysis, is what you really want. If it is, great! You have that ability and right. If it isn’t, also great! You are taking your health and life and making your own plans with it, and, god forbid, helping society a little bit too. This is what Emmanuel is saying in this article, and he is 100% correct. Please, if anyone wants to respond to this, try and give actually facts or quotes from the article to back up yourself.
First, it needs to be said that Zeke strictly avoided talking about cost in his article. His argument was all about the quality of life. But this is subterfuge. Inevitably the issue morphs into this: if someone’s quality of life is poor, why should we spend so much to maintain it?
Collectivism Generates Social Tension
Clowney is reflecting a wide spread set of beliefs. Perhaps you share them. But I think they are mistaken, or at least not fully understood. Let me try to turn off the snark and address them directly. She writes: “We DO spend too much money on the elderly and prolonging the dying process. This is a simple fact. We only have so much money, resources, time and effort to put into the health care system. Unfortunately, there is not an infinite supply of anything. So that is a real issue.”
The big problem here is “we.” Who is we? Presumably it is society as a whole. But the whole idea that we even know what the collective “we” spends is odd. Do we know what “we” spend on automobiles, housing, food, or clothing? Yes, there are statistics available on these things, but the general public has no idea. How would we know if we are spending too much or too little? And how do “we” determine what the right amount to spend should be?
(John Goodman and Mark Pauly argue that it is a fallacy that we spend more than other countries when measured by resource consumption rather than artificially set prices. See this recent article in Forbes. But that is a wholly different issue.)
The reason, of course, this comes up as a collective concern is because so much of health care spending is collectivized through government programs and employer-sponsored health insurance. The more the government spends, the higher your taxes, and the more your employer spends, the lower your wages. If we were each spending our own money, as we do for food, housing, and transportation, how much we spend would be of no general concern. Clowney would be indifferent to whether I am spending wisely or foolishly. As it is, my foolish consumption of services also raises her taxes and lowers her pay, so of course she is worried about what I do.
Now You’re Spending My Money
U.S. health care collectivism began with the passage of Medicare and Medicaid in 1965. Almost immediately there was near-panic over how much we were spending.
In “Blue Cross: What Went Wrong?” (1974), Sylvia Law wrote: “The crisis in medical care has arrived…the nation now spends a larger portion of its GNP on health care than does any other country in the world $67.2 billion, or 7 percent of GNP in 1970.” Kenneth Friedman and Stuart Rakoff were similarly agitated a few years later when they wrote: “The thrust towards greater government regulation of health services arises primarily from a single source; astronomical increases in cost. Total expenditures for health services have more than tripled since 1965, exceeding $118 billion in FY 1975. The proportion of GNP devoted to health care has grown from 5.9 to 8.3 percent.” More recently, Stuart Altman reminisced: “When I was 32 years old, I became the chief regulator in this country for health care. At that point, we were spending about 7 1⁄2 percent of our GDP on health care. The prevailing wisdom was that we were spending too much, and that if we hit 8 percent, our system would collapse.”
Note that for all their expertise, these commentators were laughably wrong. We are currently spending well over twice what they thought was the tipping point and we haven’t collapsed yet. But the idea that spending was out of control was used then, as it is now, as an excuse to impose strict controls over what is spent and on whom it should be spent. I won’t take the time here to delve into the hundreds of misguided policies this spawned throughout the 1970s and 1980s. It included everything from national health planning, to the Resource-Based Relative Value Scale and diagnosis-related groups for Medicare payments, to state-based hospital rate setting systems. All of it failed, and actually made conditions worse.
The Slippery Slope of Denying Life-Saving Care
Sooner or later, we will indeed spend too much, as Clowney argues. But is she correct that the elderly should be singled out for denial of care? Are they the sole or even the primary source of wasteful spending? I don’t think so. Once we start down the path of thinking who might be useful enough to deserve having others spend precious resources on them, we can arrive at some pretty unpleasant places. Prison inmates spring to mind. Why are we wasting money providing health care for them just so they can be healthy as they rot in jail? Does society really need to pay for a sex-change operation for Bradley Manning so he can spend the rest of his life in prison as a woman? What is the value to society of that?
What about the disabled? Emanuel thinks their lives are not worse than death, but apparently not by much. Look out, Stephen Hawking! Okay, we’ll make an exception for Hawking, but how are we to know ahead of time that he, or any other disabled person, will contribute more than he costs? Organ transplants are very expensive. Symphony conductors might be worth the cost, but probably not truck drivers.
Is this really the path we want to take? Or could there be other ways to untie this knot? Maybe we should move away from collectivism in health care spending. After all, every penny spent on healthcare ultimately comes from us, the citizenry, anyway. There is no other source. It comes from us in the form of insurance premiums, taxes, or lost wages. In the past, we trusted insurance companies, government agencies, and employers to manage our money because we thought they would do a better job than we could. But they have not done a better job. In fact, they have done a lousy job. They have given us a system that is unaccountable, inconvenient, of questionable quality, and far too expensive. We could not do worse if we managed our own money.
And, guess what? It turns out that when we manage more of our own money, we do a great job of it. The RAND Corporation has found, for example:
Total spending is reduced in high deductible health plans for both vulnerable and non-vulnerable families. High deductible plans paired with HSAs have significantly lower levels of total spending than other high deductible plans for the general population — almost 30 percent lower spending for families with a high deductible and an HSA compared to about 13 percent lower spending for similar families in other high deductible plans.
Once we control our own spending, suddenly Clowney’s (and Emanuel’s) observation makes sense. Clowney writes: “All Emmanuel is advocating is that people take matters into their own hands for THEMSELVES. Think about how you want to approach the end of your life. Think about what you want to put your children through. Think about whether spending the last 2 weeks of your life in the ICU, on ventilators and pressors and dialysis, is what you really want.”
By all means, let’s take matters into our own hands. But why start at the end of life? Let’s begin when we are still healthy and active. That way we will have a lot of practice when we near the end.