The recent announcement by the U.S. Health and Human Services Department that Medicare will pay for obesity treatments touched off much controversy.
Analysts at conservative think tanks argue that Social Security will soon be paying for diet plans, health club memberships, treadmills, stomach stapling and other expenses clearly necessitated by individuals’ own unhealthy behaviors. If history serves as an example, they argue, minor expenditures in this area will soon burgeon to multibillion-dollar outlays.
Such criticisms are correct. Supporters of the measure respond, also correctly, that we already spend billions treating ailments caused by voluntary human behavior. Smokers have bad lungs and hearts. Bikers who don’t wear helmets get brain injuries. Heavy drinkers ruin their livers. Compulsive runners and dairy farmers need arthroscopic joint surgery.
The point today is not to determine who is right in this particular dispute, but rather to argue that the dispute itself should force us closer to “discussing the undiscussable” — overt rationing of government-paid health care.
Many people hate the very phrase “rationing health care,” but every important good is rationed. Most are rationed with a market mechanism — price. The rich eat better than the poor, live in better houses, wear more expensive clothes and drive newer cars.
The rich also get better health care than the poor. For centuries, people accepted this as the natural order of things. Differential access to health care based on income is now controversial, however.
In a world without scarcity, there would be no tradeoffs. Everyone could have as much of everything as they want. We don’t live in such a world. Instead, households and governments must make difficult decisions on spending their money.
Most would agree that a just society should somehow provide minimal health care to all, regardless of income. Babies should get vaccinations, and if you have appendicitis or get hit by a bus, you ought to get treated whether you can pay or not.
Few of us, however, think justice demands unlimited government funding of nose jobs, facelifts, breast augmentation for teenagers or penile implants for octogenarians. The difficult question is where to draw the line between funding bare minimum treatments and lavishly superfluous ones.
It is a question that we must answer. As the total fraction of medical spending borne by government grows, it becomes more urgent that we face the issue squarely and soon. A decade ago, Oregon devised a system to prioritize medical procedures reimbursable through Medicaid or other public funds. A citizen commission ranked a whole array of possible procedures, considering the benefit to society versus cost. This was a very useful first step.
The Clinton administration initially challenged implementation of the priorities list for programs involving federal funds. This was knee-jerk liberalism at its worst. But the system survives and serves as an experiment and example for others to emulate. We need to take a much closer look at it for Minnesota and the nation.
© 2004 Edward Lotterman
Chanarambie Consulting, Inc.