Today, I want to express some thoughts I had after reading two articles recently related to health care. In the first article, Ezekiel Emanuel presents a lengthy argument for a life that ends promptly on reaching the age 75. In the second article, there is a one hour embedded video of Avik Roy’s proposals for managing the government’s health care cost obligations. Both are worth the time to read and absorb. I bring them together here because of my impression of a question that intersects both presentations. That question is what exactly do we want to accomplish with public policy for health care. Avik approaches his point directly with a concrete proposal based on the claim of benefits of individuals spending their own money on health care where that money has support from health savings accounts or vouchers. Ezekiel approaches his point indirectly by justifying the rationale for his own personal private decisions, but the argument appears to be an attempt to persuade others to do the same.
In recent years, the affordable care act has distorted the discussion away from cost controls and access to health care to an almost irrelevant debate on universal health insurance, how much it should cost, and what it should cover. I agree with Avik’s point that health insurance is not health care. Health insurance will pay for a service only if that service were provided.
There is still the question of whether the service is available in the first place. Cost controls of insurance limit access to health services through rationing based on calculation of urgency of need, likelihood of success, and likely outcome in terms of extending life or reaching an acceptable quality of life. In addition, cost controls may limit access where providers refuse to accept certain insurance because it does not compensate adequately to cover costs.
Rationing is also implicit in Ezekiel’s rational at least for his personal life lamenting that after a certain age, his prospects for contributing to society vanish.
Avik proposes a solution to put health care purchasing decisions in consumers hands with government assistance in the form of means-tested defined contributions from the government and for tax exempt health savings accounts that remain in possession of the individual so that the savings can compound over time. Implicit in the health cost savings is the idea of the consumer taking efforts to avoid health problems in order to continue saving money in the HSA, and when health care is needed the consumer will shop around for the best deal to limit how much he has to pay. He doesn’t mention it, but part of the savings is that people will consume fewer health services in order to save money. The good side of this self-rationing is reducing the load on the system for providing unnecessary services now taken for granted: people will be less inclined to expect a doctor’s opinion for every incident. The bad side is that people will concentrate so much on the accumulated value of the HSA at the expense of seeking early care that can be most cost effective time to address progressive illnesses.
I enjoyed reading Ezekiel’s account because it is roughly in agreement with my earlier thoughts. I emphasize that my views are very uninformed. My background is in no way a match for Ezekiel’s career as a recognized expert in health care policies and ethics. However, I had similar thoughts that health care should focus on a comfortable life to young people so that they can live a rewarding life. The question is where to draw the line of what is no longer young. Ezekiel draws the line at 75 while I would draw it about at about 55.
Part of the difference is what we expect after reaching the limit of a rewarding life. Ezekiel’s older limit makes sense because he hopes his life somehow magically ceases (he emphasizes that he opposes euthanasia) on a certain date after a long period of healthy and disease-free living. My younger limit is that I welcome living as long as possible, but only that health care spending after a certain age should no longer be a government priority. In my view, older people should still get access to health care and some of that may be government subsidized, but when it comes to rationing health care dollars and resource-constrained services, the priority should be on giving the best opportunity for younger people to enjoy a rewarding life. That priority may mean devoting resources to a sicker young person with lower prospects of recovery rather than on a person past a certain age who happens to be more likely to recover.
Ezekiel’s argument for setting an upper age limit is heavily based on society contributions although he does include the domestic family contributions. I focus more on the contribution where a rewarding life as a human primarily involves reaching adulthood with health and strength to start a family and then live to see the grand children start to enter early adulthood. Seeing grandchildren reaching a point of a promising life gives the satisfaction that your own children will have satisfying lives. I arrive at 55 by using an outdated but natural inter-generational period of about 20 years: the first born arriving at about one’s 20th birthday, the first grandchild would arrive around 40th birthday, and that grandchild will be a teenager starting to pay attention for a mate by the grandparent’s 55th birthday. Again, unlike Ezekiel’s argument, I don’t propose life ceasing at 55. I only propose that the priority for health care support should be before that age.
I recognize that my timeline is anachronistic. Modern affluent life style usually does not start a family until around 30 and postpones growing up to around 20. Using modern norms, the calculated max age for priority government funding of health care should be 80 years old, beyond even Ezekiel’s ideal good life age.
I stand by my argument for a couple reasons.
If the good life is primarily about enjoying a family life and seeing that your children are going to have successful lives, then we should follow the natural human reproductive maturity that peaks in the early 20s. When we exercise the option to postpone reproduction we are making a personal choice that our careers or wealth are more important than family life. I fully support the freedom of people to make such a choice. But if a rewarding life is obtained primarily from successfully raising a family, that project should start when it is most naturally optimal to start.
The second reason is that if we are successful in reaching this priority cutoff age in good health and disease free, we are likely to enjoy many decades of healthy life any way. Here I take issue with Ezekial’s dream of dying at 75 without access to euthanasia. If he reaches 75 comfortable, healthy, and disease free, he is likely to go on to live another 20-30 years even if he were at the point completely denied any health care services, even those he is willing to pay for himself. To me, his argument would have been much stronger if he had not stated as a wish for death at 75 but instead as a wish to no longer have access to health care after that age. Even stronger would be a wish to no longer have access to government subsidies for that health care.
The same is true once you reach 55. If you reach 55 but fail to reach at least 90, it is highly likely that the condition that leads to premature death will already be detectable if not obvious at 55. On the other hand, if our health care is successful by prioritized spending on young people, those young people will reach this cutoff age in good health and disease free. Compared with their less fortunate peers, they will be far less likely to need health care for the next couple decades.
Health care services are not perfect and there will always be those who can not reach 55 in good health and disease free. For a good portion of these people, their health problems significantly denied them a rewarding life. This is where the ethical question is most stark. We have successfully prioritized our health care spending to get these people though the young years and they are not likely to continue to survive to very old age without continued health care services. Also, because of their health conditions, they probably lacked the opportunity to amass a significant savings to pay for this care themselves.
The ethical question is justifying the withdrawal of support after reaching a certain age because we had faithfully prioritized public spending on getting them through their young years.
This gets to Avik Roy’s argument trying to appeal to moderate thinkers about the benefits of allowing people to pay health care directly with their own money (subsidized through HSAs or vouchers). The counter argument is whether we can withhold health care for someone who still needs it after exhausting his HSA savings. Avik’s plan does include an insurance plan but it is more catastrophic than the current mandated plans. The insurance benefits only apply when the disease has progressed to the point of being life threatening. While catastrophic health conditions require expensive intense care, many patients will be confronted with spending a lot of HSA funds on managing chronic health conditions to prevent those conditions progressing to the point of needing catastrophic care. Eventually, the HSA funds will run out. When that happens, the individual who previously had access to health care will no longer have access to continued care, except for catastrophic circumstances.
Before the government started to intrude on health care, the market for health care was an individual choice that allowed each individual to make his own choices about savings, insurance, and what care to seek. For many people, that choice was severely limited because of lack of affordable health insurance either due to lack of money or pre-existing health conditions that needed medical attention. The gradual progression of government regulation of health care (such as EMTALA) and health insurance (such as ACA) address the concerns of lack of access to health care for those who need it. Apparently, these acts are not sufficient so the debate continues to revise the health care system with newer proposals for closer regulation by the government.
One consequence of the government regulation of health care provisioning is that the decision is no longer a personal choice to prioritize health care expenses with other life expenses. We assume (perhaps very reasonably) that people will want health care when they need it.
When I think about the two articles at the top of this post, I think the question is how do we determine when someone needs health care. This question has fundamentally changed in terms of the entity deciding when health care is needed.
Before regulation, the individual decided when he needed care. He may choose to suffer through an illness rather than spend money to get treated. For many illnesses (including serious ones) the suffering may subside on its own without the need for care. In those cases, the patient may be endure additional suffering during the illness due to denial to access to medical care either to hasten the recovery or to relieve the symptoms. Also, the choice to avoid health care may result in long terms disfigurement or reduced quality of life. But some may make this choice in order to avoid the cost of health care using money the patient did not have or would prefer to use for other purposes.
In the modern regulation, external parties decide when care is needed. This may not be as dramatic as the poor individual above who suffered through an illness with no care at all. These parties generally will provide routine care to assess an illness and to prescribe some types of relief. When it comes to more expensive treatments, the parties will start to make a choice about whether the expense is justified.
We never had a honest and thorough debate about how to justify health care expense at the policy level.
The modern regulated environment involves mandatory cost sharing between patient and insurance (or government) through insurance premiums, deductibles, coinsurance, and uncovered expenses. It seems most of the debate is about what is the ideal balance for this kind of cost sharing. Some say patients should face a higher burden so they can make individual decisions, while others say patients should face a lower burden so they do not have a disincentive to seek more effective treatment before the illness becomes more serious.
Because we switched the decision of needing care from the patient’s choice to a choice of the government regulated insurance and health care providers markets, the question of determining need becomes a policy choice instead of a personal one. As a policy choice, we should debate what the objectives are for justifying the decisions for who needs health care.
The end of life care makes a dramatic point for illustrating different justifications, although similar arguments may apply to recoverable illnesses that can result in lengthy recovery with degraded quality of life if not treated professionally. For the end of life care, there may be several contrasting objectives to base policy:
- To meet some population statistic goal such as the nation’s life expectancy or equitable distribution of life expectancy across different groups,
- To maximize the society’s access from the individual’s contributions to society by making sure the individual is healthy through his most productive period of life,
- To maximize the family’s happiness to have access to their elder loved ones as long as possible,
- To maximize the individual’s happiness in pursuing a privately satisfying life.
From my layperson’s viewpoint, it appears the first option is the default objective. We want a health care system that produces appealing statistics across the population as a whole. The benchmark for quality of care is the relative ranking of life expectancy across different nations. We want to be near the top of that list. To reach that goal, we need to encourage people to live as long as possible.
Ezekiel Emanuel is much more informed of public policy than I am, but I suspect his article is a direct challenge to this default objectives. He should welcome a lowering of life expectancy, at least for his personal life. The problem is that it is really not his choice any more. He will likely reach his target age with good health and prospects of living for many decades beyond that age. In that case, the default objective demands that he continued living past the age he set for himself. It does not matter what he feels about it, he has to do his social duty to contribute the extension our overall life expectancy statistics.
For this reason, his article is not just a personal statement of his private wishes. He is challenging this social statistical objective. His argument is that a personally satisfying life can come from an early death that necessarily would result in a net decline in life expectancy for the country. He sets a particular age as ideal expiration date but this is still making a case for setting a national goal for life expectancy. I think he is arguing that the we should not have a goal of ever increasing the age for life expectancy. There is an ideal life expectancy beyond which we cannot justify investing our limited health care resources.
If it is ok to challenge the default objective in terms of its goals, we may also challenge the objective entirely. The other objectives I lists suggest other ways to justify policy without considering overall statistics at all.
The second objective actually makes up most Ezekiel’s argument for setting a optimal age for end of life. This objective is to support a life for the maximum contribution to society. We want a health care system that introduces healthy young people to the labor market and keeps them healthy during the period when they are most productive. He avoids a very utilitarian justification of social usefulness of individuals by including his personal family objectives of seeing his grandchildren reach maturity. However, I think the bulk of his argument is on the utility to society. Without the goal of seeing mature grandchildren when generations postpone reproduction until after starting careers, his argument suggests that 60 should be old enough. We should all die promptly at around 60 because by then most people are pretty much past the point of offering any more contributions to society. He grants himself another 15 years by considering his desire to see his grandchildren succeed.
The third objective is similar to the second except the beneficiaries are his family. His children and grandchildren benefit from his love and participation in family functions. Everyone hopes everyone will appear at the occasional family gatherings such as holiday feasts or family reunions. To make this happen, the family wants the elderly members to be available for as many years as possible. I suspect this objective is most appealing to most people. We don’t care if our loved ones are contributing anything useful to society. We just want to know they are always available for the family reunion or for a spontaneous visit. I think this objective drives the default objectives of striving to have every increasing life expectancy. The younger family members want to enjoy access to their more elderly loved one’s presence for as many years as possible.
All of the above objectives leave out the private wishes of the individual. The individual is encouraged to tolerate the financial costs or the treatment consequences of health care in order to meet other people’s goals. Death should be postponed until after the person is no longer productive, or as long as necessary to avoid emotional pain of loss for his family.
The fourth objective considers the individual’s private and selfish needs. I noted earlier that before there was a lot of regulation on health care, people made private choices for whether to obtain health care. Even in poverty conditions, some would forgo attention from community healers and folk medicinal treatments in order to avoid entangling debts or obligations. For wealthier individuals, some would make a more explicitly financial choice to suffer through an illness and accept the risks in order to preserve funds for some other purposes that may include maximizing inheritance (especially when family businesses or farms were involved). I do not know how often people chose to reject available health care, and it might have been very rare. There are at least stories that some did make this choice.
There remains this fourth objective for justifying health care decision making. This objective considers only the individuals private and selfish goals of what he feels will be a satisfying life. In areas such as participating in physically risky activities (such as extreme sports) that can result in death, we allow for the possibility that some people may find life satisfaction in pursuing an activity that can lead to early death. We could allow for the same choice for those who choose less risky use of their time.
For example, some people may want to devote most of their resources on pursuing some business project that may never succeed. They will get satisfaction from making that attempt, and they may consciously make the choice of avoiding expenses that are not related to that goal. They may rationally decide that their objective for starting a business is worth the risk of early death due to lack of health insurance.
Some people may decide to measure their life in terms of their pursuits of happiness instead of how long they may live. Like those participating in extreme sports, they hope they will survive but they rationally accept the risk that they may not. A satisfying shorter life may be more appealing than an unsatisfying longer one.
In context of private pursuits of happiness, health care presents a very expensive barrier. Moneys must be available for health insurance premiums, deductibles, coinsurance, and uncovered expenses. The health care delivery itself requires time consuming appointments and enduring the process of treatment or at least the process of stress about uncertainty of what happens next. Finally, the health care may succeed but result in a degraded capability to pursue the original dreams. If we trust a person’s decision of what is a satisfying life (like we do when we permit people to participate in extreme sports with a history of occasionally fatal accidents), then we should expect that some people may decide their pursuits of happiness are more important than access to health care.
My point in this post is not to change health care policy, but instead to note that government regulated health care policy has an implicit objective that should receive more public attention. I think part of the reason why health care debates are so intractable is that we do not have a consensus of what the objectives should be. Are the objectives primarily statistical in nature, or are the objectives to meet some utilitarian function of serving society or family? How should we consider the private selfish desires of the individual who wishes to devote his wealth (and time to earn that wealth) for purposes unrelated to health care? Should we demand people to extend their lives through brutal treatments or beyond the point where they can enjoy a personally rewarding life?
Because we do not have any discussion of the overall objectives for health care, our health care system will always appear to be broken no matter what we do. We should first agree on what exactly needs to be fixed. A clear objective will make it easier to define the qualities for a well functioning health care system.