Thursday, July 23, 2009

Health Care and the Burden of Responsibility

How much is your life worth?

This is the question that underlies most health care economics. If you have a chronic illness, and treatment costs $20,000 per year, is it worth it? Most people would say yes, of course. What if treatment cost $200,000 per year? What if you were 90 years old and treatment would add only an average of six months to your life? What if one doctor offers treatment for half the cost of another, but the cheaper doctor may not be as skilled?

These are difficult questions to answer. When we have to answer them for ourselves, spending our own money, they are hard enough. When we have to answer them for our loved ones, where differential family finances come into play, they become harder still. But when the level of responsibility is diffused further, they suddenly become easier, because more abstract. How much is the life of the other guy worth? Not more than mine, surely, and probably at least a little less.

In the United Kingdom's National Institute of Health and Clinical Excellence (NICE - and oh, how I wish C. S. Lewis were around to comment on that acronym), there exist tables that list how much your life is worth. These tables were designed by bureaucrats whose primary interest is cost control. They decide not only how much they are willing to spend to prolong your life, but how valuable certain injuries and degeneracies are. From the WSJ article:

In 2007, the board restricted access to two drugs for macular degeneration, a cause of blindness. The drug Macugen was blocked outright. The other, Lucentis, was limited to a particular category of individuals with the disease, restricting it to about one in five sufferers. Even then, the drug was only approved for use in one eye, meaning those lucky enough to get it would still go blind in the other.

The decision tree basically goes like this: Blindness reduces your quality of life by X (some percentage), and lasts the rest of your life. Let's say your life expectancy is 15 more years. Then blindness costs you 15X "quality adjusted life years." The value of a quality adjusted life year is Y. If the cost of treatment is more than 15XY, then you are out of luck. NICE is purely practical, not really "nice" at all.

What NICE does provide, though, is psychological cover. If you had to pay for your own health care, then you would have to work out the costs and benefits on your own. Suppose you simply didn't have and couldn't borrow the money for some treatment. You might then ask relatives to help out. But this produces a pretty problem for them: if the cost were relatively low, they would probably help, but as costs go up, at a certain point that help may actually start harming other relatives. Family members might have to pick and choose: do we help prolong Grandma's life by another year so she can see her first great-grandchild, or do we spend that money to help stop Dad's macular degeneration?

When the government runs everything, these problems are out of your hands. NICE might help neither, just one, or both, but in no case do you have to feel guilty about it. You have no choice in the matter. All you have left is some small say in the total health care budget, expressed via your vote.

The question of whether the burden of personal and family responsibility is worth the value of choice is related to more general ones: Does choice make us happy? Is choice a "good"? I will take up this question in more detail at another time. For the time being, let us take it as given that choice is good, by the following argument. Choice is related to liberty, so if we value liberty of itself (that is, we value liberty before considering the other things, positive and negative, that liberty brings), then we should also value choice of itself.

Still, is the burden worth it? I think that is a question that many people would answer in the negative. But if we actually get nationalized health care in the style of the U.K. (whether intentionally or not; an analysis by the Lewin Group suggests that the The American Affordable Health Choices Act of 2009 currently under discussion in Congress would shift about 100 million people - 2/3 of all privately-covered individuals - to the "public plan"), then we will almost certainly pay less for less health care. And that question is what really should be front and center: is the burden of individual responsibility worth it to get - in the aggregate, at least - more and better health care? When put this way, I think most people's answers would shift to assent.

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