# The Healthcare Debate: Confronting Reality (End of Life Care and Costly Chronic Diseases)

Two weeks ago, I began writing the draft to this post, based on an Ann Coulter interview from February 3rd. And then on February 9th, Scott published his ‘cost disease’ article addressing rising healthcare costs. It just goes to show how we’re all thinking about the same stuff even though our inspirations come from different sources.

An excerpt from a radio show with Ann Coulter, Ann Coulter’s Report Card for President Trump’s First Two Weeks: ‘I Give Him an A+++’:

“That’s all it is, Alex. We just want the free market applied to health insurance, and forget about boring us with your sob-story cases. Okay, some of them are genuine sob stories; I don’t mean to be unkind about that, but it’s a tiny, tiny, tiny minority of people who just happen to have kids or they themselves are born with some horrible condition. Just let me buy it on the free market the same way I buy shoes, and books, and milk, and, by the way, car insurance, renters’ insurance, homeowners’ insurance,” Coulter exclaimed.

“The Soviets declared everything a fundamental human right, and you couldn’t get bread,” she said in response to the argument that citizens have a “right” to “free” health care. “Apparently describing something as a fundamental human right is the fastest way to make sure there is none of it, and it’s very expensive. Sell it on the free market, and you’ll have plenty of it, lots of choices, and everything you want.”

“I also love something what Trump got attacked for in the debates, which I also describe in In Trump We Trust: he said there are three categories. There are 319 million people in the country in the category you were just describing: ‘Please just let us buy this product,’ which is now illegal in America, to purchase. That’s the letter I got. My insurance, made illegal,” she said.

“Anyway, that’s 319 million. Then there are a few million who are incompetent, lazy, they won’t have health insurance. Okay, as Trump said in the debates, we’ll take care of them on a different system. Maybe it’s Medicaid for all of them. Maybe they’re poor, they’re young, they’re millennials. Whatever it is, we’re not going to let people die in the street – a sentence that both Ted Cruz and Rand Paul attacked Trump for. Of course, we’re going to let people die in the street, but you don’t have to wreck Ann’s health care to take care of them,” Coulter asserted.

“And then the third category, which is the tiniest category of all, are people who just got a band hand in life. We’re happy to help someone who was born with some genetic condition. That’s separate. We’ll pay for them. We could give them all $10 million, and it would be cheaper than the current Obamacare,” she said. The above passage highlights the fundamental problem with the healthcare debate – both for the ‘left’ and, regrettably, the ‘right’, too. As is often the case, the same liberals who hold Darwin sacrosanct, Darwinism doesn’t apply to healthcare, where every life is sacred and worth saving at any cost. The same goes for welfare spending, in which billions of dollars every year are transferred from the ‘fit’ to pay for the ‘unfit’, whose survival depends on this assistance. But doesn’t the left’s support of ‘choice’ and euthanasia contradict this? Not necessarily, because for the left, ‘choice’ is about lifestyle and ‘female empowerment’, not utilitarianism or pragmatism. As soon as soon as you frame the abortion or euthanasia debate in terms of practical, quantifiable matters such as healthcare spending, welfare and entitlement spending, crime, or heaven forbid, race, the left suddenly becomes pro-life. For example, in 2015 UK presenter Katie Hopkins (the Brits to their credit at least invented HBD) was attacked by the left for pointing out the obvious but politically incorrect observation that dementia patients, who have no hope of survival (because dementia is incurable and tends to affect the elderly), are using public healthcare services that could otherwise go to patients with better prognostic factors. The mass stupidity in 2014-2015 that was the ALS ice bucket challenge was also backed by the left. In 2001, it was mainly the ‘left’ who attacked Levitt and Donohue for positing a link between abortion and crime reduction. A diagnosis of Dementia, duchenne muscular dystrophy, or ALS, as awful and tragic as those diseases are, is Darwin’s way of saying ‘it’s time to go’ or ‘you’re not fit, sorry’. Granted, there are some on the left who support euthanasia from a utilitarian and pragmatic perspective, as a way to reduce both suffering and healthcare costs, but they seem to be the minority. Just as the ‘left’ extols Darwin in theory (and also as way of opposing Christianity, it seems) but opposes Darwinism in practice, some on the ‘right’ also seem to cling to fanciful beliefs about healthcare, and to an extent, abortion, as Ann Coulter’s reply demonstrates. The ‘right’ champions free market solutions to healthcare, and in my own criticism of Obamacare I tend to agree a free market approach is better than a ‘statist’ one, but many on the right don’t want to accept that free market solutions may not yield outcomes that are socially, aesthetically, or morally desirable (also known as the ‘ick’ factor). ‘Free market’ just becomes a giant magical rug to sweep all problems under. There is nothing that can’t be solved with the magical wand of the ‘free market’, and the outcome is always one that is pleasing. From a transcript: “it’s a tiny, tiny, tiny minority of people who just happen to have kids or they themselves are born with some horrible condition.” But this tiny minority consumes a lot of resources…that’s the problem…and it’s not so tiny in many instances. For example, Ann ignores end-of-life care, which consumes 25% of Medicare spending. One out of every four Medicare dollars, more than$125 billion, is spent on services for the 5% of beneficiaries in their last year of life.

The cost of keeping the terminally ill alive

Last year, Medicare paid $55 billion just for doctor and hospital bills during the last two months of patients’ lives. And it has been estimated that 20 to 30 percent of these medical expenses may have had no meaningful impact. Most of the bills are paid for by the federal government with few or no questions asked. This statistic is from a 60 Minutes story on “The Cost of Dying” and is one reason our healthcare system is in trouble. Ann’s$10 million figure to cover rare genetic conditions is also hardly sufficient (unless it’s per patient, which would be too much). Nationally, treating ALS, DMD and MMD combined is $1.07 to$1.37 billion per year. This is a conservative figure–the actual cost is probably two to four times higher.

A minority of patients contributes to the bulk of healthcare spending:

This means adults with chronic diseases, cancer, end-of-life care, and, sadly, children with terminal conditions. Jim keeps mentioning drug addicts and vagrants, which are an easy target (because who likes drug addicts and vagrants), but this is only a fraction of the problem. Drug addiction abuse costs $75 billion annually to insurers, which is just 1/27 of the$2 trillion spent on total health care and 1/13 of the $1 trillion spent on the most costly of patients. [2] In a free market system, defective products are either discounted or discarded, but this does not always apply to people, who are above this sorting process due to the invocation of ‘moral/ethical conscience’, which is supposed to override the free market–or–the free market is supposed to somehow, magically, cover such spending. A typical person has lifetime earnings of$1-2 million ($50k a year times 40 years). From a free market perspective, it makes sense to provide treatment for child or adult who has an entire (or most) lifetime to become economically productive. But it becomes much harder to justify care for children with rare genetic diseases, who will die before before becoming economically productive, or for the elderly who have no savings to pay for treatment and are well-past their ability to produce economic value. For clarity, we’re talking about ‘public goods’. A billionaire can afford whatever costly treatments he wants, but the question is how should public goods be rationed/allocated. ‘Rationing’ has become the third rail of policy discourse because it invokes Kafkaesque imagery of ‘death panels’, but there is no escaping the reality that all finite resources must in some way be rationed, whether it’s a free-market system or government-run system. Again, 5% of the US population accounts for 50% of healthcare spending–how does a free market approach, which is motivated by profits, handle so many unprofitable patients, in which there is no hope of recouping the often futile, palliative treatment costs? And spending for Medicare and Medicaid is projected to be much higher both in nominal terms and relative to GDP: To privatize healthcare means that the private sector would have to cover this spending, which likely means rates would have to go up and or healthcare would have to be denied in certain instances. It seems like wishful thinking to assume total privatization will lower costs, be profitable for insurers and providers, and provide healthcare for everyone who needs it, including costly incurable diseases and costly end-of-life care. Any insurance program, either private or pubic, needs a lot of members to be profitable, because a minority of patients will consume the bulk of the costs. An obvious problem is it’s hard to motivate people, especially the young, to pay for heath insurance when they are healthy–people tend to want healthcare when they are sick but think they are invincible otherwise. Because there is an aversion to paying for something when it’s not immediately needed, an alternative privatization idea is to deduct healthcare costs out of the patient’s future earnings, but as mentioned above, for patients with terminal and or very costly diseases, this is unprofitable. Even the assumption that privatization will significantly lower costs is on shaky grounds, as shown by Megan McArdle: But we already have a public option. As mentioned, we have several. And Medicare doesn’t control costs noticeably better than the private sector does: Medicaid controls costs significantly better. That’s because it’s a program for poor people who don’t vote much, and politicians don’t necessarily care if doctors refuse to take it. So states set reimbursement rates that are so low that you could pay more to take your kid to Panera than the government would pay for you to take him to see a general practitioner. From 1990-2011, the difference in excess costs between ‘medicaid’ and ‘other’ (private) is just 1.7% vs. 1.5%. Costs are rising to pay for so-called ‘futile care’. Instead of healthcare saving lives, it’s about prolonging death at great cost: Kids With Costly Medical Issues Get Help, But Not Enough “Katie hit a million [dollars] in her first year of life,” says Marcy Doderer, Katie’s mother. Katie used to require 24-hour nursing; now the nurse only comes at night, but it still costs almost$75,000 a year, by Marcy’s estimate. It’s a service that most private insurance doesn’t cover. It is, however, paid for by Katie’s Medicaid coverage—even though the family is well-off.

The sickest 2 million kids account for about 40 percent of Medicaid’s total spending on children. Many of these children have a combination of private insurance and Medicaid, and it can be challenging to coordinate care and coverage. Marcy Doderer, who until recently was the CEO of the children’s hospital in San Antonio, Texas, acknowledges that her job gives her family an advantage.

That’s a lot of money for a single child, when from a utilitarian standpoint the ‘greater good’ could be maximized by allocating the \$1 million of medicaid assistance to multiple children who have better prognosis.

I go after the ‘left’ on this blog a lot. Now it’s the right’s turn, for foot-dragging on HBD-based solutions to healthcare (as well as crime and entitlement spending (as the ‘abortion, eugenics, welfare, and crime’ series shows [1])). The ‘sanctity of life’ can be very expensive, as the above example shows. The ‘right’, who complain about deficits and spending, need to confront this, just as the ‘left’ does, too. That’s why, despite being on the ‘right’, I agree that allowing children to be born with severe disease could be child abuse:

Such screening wouldn’t prevent all genetic disease (it would miss disease due to very rare or unknown mutations, or due to de novo mutations occurring in the child), but it would certainly have a dramatic impact on the number of children born with horrible diseases such as cystic fibrosis and Duchenne muscular dystrophy.

In earlier posts Abortion & Healthcare Policy and The Abortion Plan, I advocate incentive-based solutions, such as paying married couples who have inauspicious genetic factors to not procreate unless they have the financial means to care for a special-needs child.

Naturally there are objections to embryo screening among religious conservatives who believe that inflicting severe disease on children is the will of God – but why does the prospect raise such unease among even the secular community? I share Le Page’s puzzlement on this question, and would invite opponents to lay out any well-reasoned arguments against routine screening in the comments below.

Again, the ‘left’ has a love/hate relationship with science. But this also applies to some on the ‘right’ too. Naturally, people are squeamish at the idea of quantifying the value of human life, as explained in Abortion and Healthcare Policy:

Some people find the idea of utilitarianism, as well as thought experiments such as the trolley car, to be an affront to their moral sensibilities, since sometimes the most optimal allocation of a resource often comes at a cost to something someone else holds dear. Some are unsettled by the idea that the value of a human can be reduced to a number, but if you have insurance (health, auto, home) – that is exactly what it is, an attempt to assign a monetary value to a human life in order to price a policy, yet when the argument is framed differently (trolley car or abortion), these very people become mortified at the premise that human life does indeed have a finite value, or that some lives may be more valuable than others. ‘Pro life’ taken to its extreme would be mean no war and no death penalty – both positions many Republicans, who identify as ‘pro life’, support. So why does this contradiction exist? I suppose because they rationalize from a utilitarian standpoint that the possible loss of some innocent lives (the occasionally wrongly executed individual, soldiers dying, or collateral damage) indirectly serves a ‘greater good’ (preventing more deaths both directly and indirectly), justifying this utilitarian risk/reward trade-off.

And from Forbes, why is so much money spent on end of life care, when the evidence suggests it’s counterproductive?

It seems that no matter how much money you use during that last year/month, if the person is sick enough, the effort makes things worse. A lot of the money being spent is not only not helping, it is making that patient endure more bad experiences on a daily basis. The patient’s quality of life is being sacrificed by increasing the cost of death.

Why don’t more institutions move to palliative care quicker when they see the obvious trends in their patients? Joe Klein wrote a cover story for Time about his experience with his parents and their end-of-life experience. Anyone who has gone through a similar process can not only empathize, but will become emotional because that last year/month can be a genuinely awful experience for all concerned. So, with all this data and personal experience, why do we continue to reward a system that pushes life-at-all-costs instead of quality of life?

This is a good question. To put on my ‘Scott hat’ (in which I consider the other side of the argument), there is an anecdote about Robert Heinlein in which he was asked about cannibalism: if someone is dead, does it matter what we do with the body–to which Heinlein answered that we do not want to live in a society in which people have acquired a taste for human flesh. Similarly, do we want to live in a society where we euthanize, sterilize, or abort-away all our problems. This also invokes a ‘slippery slope’ argument: if we begin with those who are most inconvenient, why stop there. How about those who are only a ‘medium inconvenience’, and so on.

Going back to the idealism v. materialism post, a materialist may argue that consciousness and being are entirely physical (eliminative materialism), without spirit or a soul–hence a quantifiable, material value (economic or scientific) can be ascribed to individual life, justifying euthanasia and organ transplantation, as consciousness is inseparable from the brain, so if the brain empirically appears dead (diminished or absence of brain activity in response to stimuli), so too is consciousness and the body. This is the opposite view as espoused by dualism. An idealist, on the other hand, is not convinced, arguing that there are aspects of ‘being’ that are not physical (ontological argument). Epistemologically, an idealist may argue that there are imitations to what what we can know about consciousness or the value of human life, that can’t be measured by a machine or economic value (limitations of knowledge). In his mind, the idealist rationalizes that the patient has some form of sentience despite the empirical evidence showing otherwise.

The issue of fairness comes up–is it fair to deny life and birth to some.

A second reason is that diseases that are intractable now may become curable or treatable later, so by ‘giving up’, we not only deny hope for future patients, but technological and medical progress stagnates. The path of least resistance now may come at a greater cost later. Recent examples include childhood leukemia, thyroid cancer, and testicular caner, once fatal but now both highly curable. But given how costs are exploding, we better find more cures–fast.

However, life expectancy hasn’t budged much, excluding mortality within the first four years of life. Thomas Hobbes and John Adams lived to 90, a rarity even today (despite hundreds of billions spent every year trying to prolonging life). Ultimately, we cannot solve the healthcare crisis with wishful thinking…when a company is losing money, the usual response is to cut costs by discontinuing the divisions or services that are unprofitable. A restaurant, for example, may close stores. But the response by politicians is the opposite one, which is to continue what isn’t working.

Part 2 goes into greater detail about rising healthcare (and also education) costs.

[1] Related posts in the “abortion, eugenics, welfare, and crime” series:

Abortion and Crime – When Political Correctness and Partisan Politics Gets in the Way of Promising Research and Policy

Is partisanship holding back good policy in the abortion debate?

Could Republicans Endorse Eugenics?

[2] Jim’s approach is a purely rational, seldom citing links and data. Scott, despite being labeled a ‘rationalist’, actually much more of an empiricist, citing tons of links and data in his articles.

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