Tuesday, April 18, 2017

Selective denial or 'rationing' of health care?

According to Karl Denninger, it's likely in due course, thanks to budget pressures.

I claim no special power here, nor any inside information.  This is simply arithmetic coupled with logic.

. . .

... on the math, we have roughly 5 years before the US Federal Government will attempt to spend $2 trillion a year between Medicare and Medicaid annually, $600 billion more on a yearly basis than it spends now.  It may try to forcibly shift some of the Medicaid spending to the States (as the AHCA did) but the bottom line will continue to expand at its ~9% annualized rate.

That cannot be financed.

It is mathematically impossible to do so, and thus it will not happen.

If the government tries to "print" it (via Fed machinations) doing so will further depress productivity which will go negative from its already-suppressed levels (as a result of the last ten years of deficit spending) and at that point GDP collapses and so do asset prices and tax revenue.

So they won't do that either because unlike in 2007 when the total between those two programs was $830 billion they can't get away with it at nearly three times the price.

What they'll probably do instead, therefore, is unilaterally and sadistically cut people off.

If you're one of them you will either suffer, die or (probably) both and they'll target those who are both fat and sick figuring, quite properly, that you'll be physically unable to do anything about it.

The low-hanging fruit, where a full 25% of the spending happens today, is on Type II diabetes.

If you're Type II diabetic you're ****ed, in short.  You better fix that if you can, right now.

If you're overweight and especially if you're obese you had better fix that too, right now, because that has a very high probability of leading to Type II diabetes.

It is my prediction that this is where they'll target first.

There's more at the link.  Scary, but recommended reading.

I think Mr. Denninger is probably both right and wrong.
  • He's probably right, in the sense that such 'rationing' of health care is already taking place, discriminating against smokers.  There have been many reports that smokers are being denied surgery and other health care options because their habit makes it more difficult to produce a satisfactory outcome.  That's the cause of much debate at present, in the health care community and in the wider civil rights arena.  It's not much of a jump from there, to rationing health care to obese people or those suffering from diabetes.
  • He's probably wrong, in that overweight and obese people (which includes many diabetics) make up a very large proportion of the US electorate.  Any attempt by any administration, Republican or Democrat, to cut health care to these people would result in a ****storm that would make present political tensions seem like a minor disagreement at a Sunday School kids' party.  I suspect neither political party will risk that - at least, not overtly.

What I suspect is more likely to happen is that rationing will occur 'administratively'.  Bureaucrats will craft rules and regulations that will never be referred to Congress (which will tacitly condone them by not taking action to stop them).  Those rules and regulations will predicate that health care expenditure will be incentivized by the government on the basis of the success achieved by local hospitals and other facilities.  The definition of 'success' may also be modified.  This will allow bureaucrats to control access to health care in terms of cold, hard cash.
  • Your surgeons have a 60% success rate?  That's terrible!  We're denying you incentive payments until you improve.
  • Your surgeons have an 80% success rate?  That's pretty good.  Here, have some more subsidy money.
  • Your surgeons have a 95% success rate?  Outstanding!  Here's more subsidy money and bonuses for your heads of department, to distribute among their medical staff at their discretion.

Money talks.  Once that sort of politically-correct bribery becomes common, you can expect hospital admissions staff to be very cautious about approving surgery for those less likely to recover quickly and/or fully from it.  That will, of course, include smokers, the obese, and diabetics.  Their reduced chances of health care success will impact the 'success' of the facility as a whole - and, therefore, the financial incentives it receives.  Such patients will therefore run into delays, and paperwork issues, and demands for more tests (at their expense, of course) to 'ensure that they can safely undergo surgery', and every other administrative roadblock that can be imagined.

I hit those problems last year, when I needed gall bladder surgery.  The fact that I'm a heart attack and bypass surgery survivor, and have a fused spine and other complicating factors, meant that the hospital demanded 'cardiac clearance' before it would proceed with the operation.  I'd had two kidney stone procedures just the year before, under general anesthetic, with no problems whatsoever, but they refused to take that into account.  I had to jump through all the hoops, all over again.  I was infuriated, but what could I do?  They weren't refusing surgery to me - just demanding extra steps, and extra costs, before proceeding.  If I couldn't or wouldn't have complied, there would have been no surgery for me;  but that would have been regarded as my fault, not theirs, because I'd 'failed to comply' with their 'reasonable requests' and procedures.

I suspect more and more of us will encounter such demands in future.  It's a form of health care rationing, whether we recognize it as such or not.  It also allows health care providers to take care of each other, by ensuring that they 'spread the wealth around', making patients spend money unnecessarily on procedures and tests they don't really need.

Thus, health care rationing will probably be applied, but I suspect it'll be administratively and financially, rather than by overt denial of care to specific classes of people.  That doesn't make it any easier or more bearable if, as I am, you're in one of the high-risk population groups for denial, of course.  Sucks to be older or less healthy, I guess . . .



SiGraybeard said...

Or, we could emulate the British NHS and implement something like the "Liverpool Pathway", which is to deny care to anyone they think isn't cost effective. If hospitalized, they'll sedate and deny food and water to them until the patient dies off. Originally intended for "terminal" patients, denying them water made it a self-fulfilling diagnosis. It eventually got applied to babies that required inconvenient amounts of care.

The Brits, Canadians, and other paragons of compassion deny many types of common procedures, like hip replacements, to the obese because they need suffer more.

Obamacare was designed in part by advocates of the "whole lives system". That system openly says it's OK to screw you over and deny you care when you're 70, and not screw over someone who's 25 because anyone who's 70 now was 25 at one time, and the majority of those who are 25 now will be 70 some day". In other words, "we can screw you now because we didn't screw you earlier; and if we're not screwing you now, wait until you're 70 and then you'll really be screwed." PDF of the article the whole lives approach is based on.

Anonymous said...

It is simple economics. The first rule of economics is that resources are limited, but human desires are unlimited. Any economic system- socialism, free market etc must put in place a limitation on consumption, or all resources will be used until consumed.

Under the free market, the limited on consumption of health care is that we are limited to the health care we can or are willing to pay for ourselves.

Under single payer or government care, limitations are still present, but the decisions are not made by the patient but by the government. Thus rationing, long wait times and poor quality care.

Anonymous said...

Trying to starve an old woman to death because she has pneumonia:


Dead old people are cheaper than live ones; the gov pays so they make the decision.

Jonathan H said...

The other way to ration care is by reducing reimbursement rates below the cost of service - there are already many doctors who won't accept new medicaid/ medicare patients because they lose money doing it; if Congress ever 'forgets' to pass the 'doc fix', rates will further drop and even more people will have trouble getting care.
As people have been saying, if something can't go on forever - IT WON'T!

Quentin said...

If America were to adopt UHC, it would save approx $1T.

Quartermaster said...

What was being done to you is called defensive medicine.

Quentin, UHC would runs costs up unless you ration care as the British NHS does.

tweell said...

I managed to stop just short of diabetes (had an A1C of 10.4, 2 years later it's 4.9) by losing weight and drastically changing my diet. Carbohydrates tempt me, but I will not give into temptation. I will not become dependent on modern medicine to keep me alive because I could not resist sweets.

Quentin said...

> Quentin, UHC would runs costs up unless you ration care as the British NHS does.

You do realise that we have private health care on top? And I included the cost of that in the savings?

Don't let the search for the perfect get in the way of the good enough.

Joe Mama said...

"Quick! Dump the patient on the floor. The surgery is a success if the patient is not on the table when he codes!"

Kirk said...

If you are a type 2 diabetic, the most effective treatment is barbell strength training. Dr Jordan Feigenbaum talks about the effects on diabetes at the 24:40 mark here: https://youtu.be/7tsTwcOb_0k