Singer on rationing health care

Peter Singer, a prominent utilitarian philospher, has set out a very strong case that ‘rationing’ health care is both inevitable and ethically sound, if done intelligently. The inevitability of rationing arises inescapably from the fact that our resources to do all things are limited, that we don’t want to devote all of our resources to health care, and that no amount of resources can prevent death indefinitely or in all cases. As such, we need to make sure that the rationing is driven by intelligent considerations, rather than morally dubious ones such as the wealth of the person receiving treatment.

If the U.S. system spent less on expensive treatments for those who, with or without the drugs, have at most a few months to live, it would be better able to save the lives of more people who, if they get the treatment they need, might live for several decades.

Pragmatically, it isn’t possible to prevent the wealthy from spending whatever they can on their own health care. Even if you outlaw it domestically, there are plenty of other states that will welcome their cash. What is possible is improving outcomes in situations where risk and resources are being pooled, whether by private ensurers or by government-run insurance schemes. It is in those cases that we need to do a good job of evaluating what expenditures produce benefits sufficiently large to justify them, and which we must decline to undertake.

Author: Milan

In the spring of 2005, I graduated from the University of British Columbia with a degree in International Relations and a general focus in the area of environmental politics. In the fall of 2005, I began reading for an M.Phil in IR at Wadham College, Oxford. Outside school, I am very interested in photography, writing, and the outdoors. I am writing this blog to keep in touch with friends and family around the world, provide a more personal view of graduate student life in Oxford, and pass on some lessons I've learned here.

86 thoughts on “Singer on rationing health care”

  1. July 19, 2009
    Why We Must Ration Health Care

    You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?

    If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.

    In the current U.S. debate over health care reform, “rationing” has become a dirty word. Meeting last month with five governors, President Obama urged them to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintons’ attempt to achieve reform. In a Wall Street Journal op-ed published at the end of last year with the headline “Obama Will Ration Your Health Care,” Sally Pipes, C.E.O. of the conservative Pacific Research Institute, described how in Britain the national health service does not pay for drugs that are regarded as not offering good value for money, and added, “Americans will not put up with such limits, nor will our elected representatives.” And the Democratic chair of the Senate Finance Committee, Senator Max Baucus, told CNSNews in April, “There is no rationing of health care at all” in the proposed reform.

    Remember the joke about the man who asks a woman if she would have sex with him for a million dollars? She reflects for a few moments and then answers that she would. “So,” he says, “would you have sex with me for $50?” Indignantly, she exclaims, “What kind of a woman do you think I am?” He replies: “We’ve already established that. Now we’re just haggling about the price.” The man’s response implies that if a woman will sell herself at any price, she is a prostitute. The way we regard rationing in health care seems to rest on a similar assumption, that it’s immoral to apply monetary considerations to saving lives — but is that stance tenable?

    Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. But our current system of employer-financed health insurance exists only because the federal government encouraged it by making the premiums tax deductible. That is, in effect, a more than $200 billion government subsidy for health care. In the public sector, primarily Medicare, Medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals.

    The case for explicit health care rationing in the United States starts with the difficulty of thinking of any other way in which we can continue to provide adequate health care to people on Medicaid and Medicare, let alone extend coverage to those who do not now have it. Health-insurance premiums have more than doubled in a decade, rising four times faster than wages. In May, Medicare’s trustees warned that the program’s biggest fund is heading for insolvency in just eight years. Health care now absorbs about one dollar in every six the nation spends, a figure that far exceeds the share spent by any other nation. According to the Congressional Budget Office, it is on track to double by 2035.

    President Obama has said plainly that America’s health care system is broken. It is, he has said, by far the most significant driver of America’s long-term debt and deficits. It is hard to see how the nation as a whole can remain competitive if in 26 years we are spending nearly a third of what we earn on health care, while other industrialized nations are spending far less but achieving health outcomes as good as, or better than, ours.

    Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?

    Last year Britain’s National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE, is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year. Sutent, when used for advanced kidney cancer, cost more than that, and research suggested it offered only about six months extra life. But the British media leapt on the theme of penny-pinching bureaucrats sentencing sick people to death. The issue was then picked up by the U.S. news media and by those lobbying against health care reform in the United States. An article in The New York Times last December featured Bruce Hardy, a kidney-cancer patient whose wife, Joy, said, “It’s hard to know that there is something out there that could help but they’re saying you can’t have it because of cost.” Then she asked the classic question: “What price is life?”

    Last November, Bloomberg News focused on Jack Rosser, who was 57 at the time and whose doctor had told him that with Sutent he might live long enough to see his 1-year-old daughter, Emma, enter primary school. Rosser’s wife, Jenny, is quoted as saying: “It’s immoral. They are sentencing him to die.” In the conservative monthly The American Spectator, David Catron, a health care consultant, describes Rosser as “one of NICE’s many victims” and writes that NICE “regularly hands down death sentences to gravely ill patients.” Linking the British system with Democratic proposals for reforming health care in the United States, Catron asked whether we really deserve a health care system in which “soulless bureaucrats arbitrarily put a dollar value on our lives.” (In March, NICE issued a final ruling on Sutent. Because of how few patients need the drug and because of special end-of-life considerations, it recommended that the drug be provided by the National Health Service to patients with advanced kidney cancer.)

    There’s no doubt that it’s tough — politically, emotionally and ethically — to make a decision that means that someone will die sooner than they would have if the decision had gone the other way. But if the stories of Bruce Hardy and Jack Rosser lead us to think badly of the British system of rationing health care, we should remind ourselves that the U.S. system also results in people going without life-saving treatment — it just does so less visibly. Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits set by NICE. American patients, even if they are covered by Medicare or Medicaid, often cannot afford the copayments for drugs. That’s rationing too, by ability to pay.

    Dr. Art Kellermann, associate dean for public policy at Emory School of Medicine in Atlanta, recently wrote of a woman who came into his emergency room in critical condition because a blood vessel had burst in her brain. She was uninsured and had chosen to buy food for her children instead of spending money on her blood-pressure medicine. In the emergency room, she received excellent high-tech medical care, but by the time she got there, it was too late to save her.

    A New York Times report on the high costs of some drugs illustrates the problem. Chuck Stauffer, an Oregon farmer, found that his prescription-drug insurance left him to pay $5,500 for his first 42 days of Temodar, a drug used to treat brain tumors, and $1,700 a month after that. For Medicare patients drug costs can be even higher, because Medicare can require a copayment of 25 percent of the cost of the drug. For Gleevec, a drug that is effective against some forms of leukemia and some gastrointestinal tumors, that one-quarter of the cost can run to $40,000 a year.

    In Britain, everyone has health insurance. In the U.S., some 45 million do not, and nor are they entitled to any health care at all, unless they can get themselves to an emergency room. Hospitals are prohibited from turning away anyone who will be endangered by being refused treatment. But even in emergency rooms, people without health insurance may receive less health care than those with insurance. Joseph Doyle, a professor of economics at the Sloan School of Management at M.I.T., studied the records of people in Wisconsin who were injured in severe automobile accidents and had no choice but to go to the hospital. He estimated that those who had no health insurance received 20 percent less care and had a death rate 37 percent higher than those with health insurance. This difference held up even when those without health insurance were compared with those without automobile insurance, and with those on Medicaid — groups with whom they share some characteristics that might affect treatment. The lack of insurance seems to be what caused the greater number of deaths.

    When the media feature someone like Bruce Hardy or Jack Rosser, we readily relate to individuals who are harmed by a government agency’s decision to limit the cost of health care. But we tend not to hear about — and thus don’t identify with — the particular individuals who die in emergency rooms because they have no health insurance. This “identifiable victim” effect, well documented by psychologists, creates a dangerous bias in our thinking. Doyle’s figures suggest that if those Wisconsin accident victims without health insurance had received equivalent care to those with it, the additional health care would have cost about $220,000 for each life saved. Those who died were on average around 30 years old and could have been expected to live for at least another 40 years; this means that had they survived their accidents, the cost per extra year of life would have been no more than $5,500 — a small fraction of the $49,000 that NICE recommends the British National Health Service should be ready to pay to give a patient an extra year of life. If the U.S. system spent less on expensive treatments for those who, with or without the drugs, have at most a few months to live, it would be better able to save the lives of more people who, if they get the treatment they need, might live for several decades.

    Estimates of the number of U.S. deaths caused annually by the absence of universal health insurance go as high as 20,000. One study concluded that in the age group 55 to 64 alone, more than 13,000 extra deaths a year may be attributed to the lack of insurance coverage. But the estimates vary because Americans without health insurance are more likely, for example, to smoke than Americans with health insurance, and sorting out the role that the lack of insurance plays is difficult. Richard Kronick, a professor at the School of Medicine at the University of California, San Diego, cautiously concludes from his own study that there is little evidence to suggest that extending health insurance to all Americans would have a large effect on the number of deaths in the United States. That doesn’t mean that it wouldn’t; we simply don’t know if it would.

    In any case, it isn’t only uninsured Americans who can’t afford treatment. President Obama has spoken about his mother, who died from ovarian cancer in 1995. The president said that in the last weeks of her life, his mother “was spending too much time worrying about whether her health insurance would cover her bills” — an experience, the president went on to say, that his mother shared with millions of other Americans. It is also an experience more common in the United States than in other developed countries. A recent Commonwealth Fund study led by Cathy Schoen and Robin Osborn surveyed adults with chronic illness in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom and the United States. Far more Americans reported forgoing health care because of cost. More than half (54 percent) reported not filling a prescription, not visiting a doctor when sick or not getting recommended care. In comparison, in the United Kingdom the figure was 13 percent, and in the Netherlands, only 7 percent. Even among Americans with insurance, 43 percent reported that cost was a problem that had limited the treatment they received. According to a 2007 study led by David Himmelstein, more than 60 percent of all bankruptcies are related to illness, with many of these specifically caused by medical bills, even among those who have health insurance. In Canada the incidence of bankruptcy related to illness is much lower.

    When a Washington Post journalist asked Daniel Zemel, a Washington rabbi, what he thought about federal agencies putting a dollar value on human life, the rabbi cited a Jewish teaching explaining that if you put one human life on one side of a scale, and you put the rest of the world on the other side, the scale is balanced equally. Perhaps that is how those who resist health care rationing think. But we already put a dollar value on human life. If the Department of Transportation, for example, followed rabbinical teachings it would exhaust its entire budget on road safety. Fortunately the department sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million. Other government agencies do the same. Last year the Consumer Product Safety Commission considered a proposal to make mattresses less likely to catch fire. Information from the industry suggested that the new standard would cost $343 million to implement, but the Consumer Product Safety Commission calculated that it would save 270 lives a year — and since it valued a human life at around $5 million, that made the new standard a good value. If we are going to have consumer-safety regulation at all, we need some idea of how much safety is worth buying. Like health care bureaucrats, consumer-safety bureaucrats sometimes decide that saving a human life is not worth the expense. Twenty years ago, the National Research Council, an arm of the National Academy of Sciences, examined a proposal for installing seat belts in all school buses. It estimated that doing so would save, on average, one life per year, at a cost of $40 million. After that, support for the proposal faded away. So why is it that those who accept that we put a price on life when it comes to consumer safety refuse to accept it when it comes to health care?

    Of course, it’s one thing to accept that there’s a limit to how much we should spend to save a human life, and another to set that limit. The dollar value that bureaucrats place on a generic human life is intended to reflect social values, as revealed in our behavior. It is the answer to the question “How much are you willing to pay to save your life?” — except that, of course, if you asked that question of people who were facing death, they would be prepared to pay almost anything to save their lives. So instead, economists note how much people are prepared to pay to reduce the risk that they will die. How much will people pay for air bags in a car, for instance? Once you know how much they will pay for a specified reduction in risk, you multiply the amount that people are willing to pay by how much the risk has been reduced, and then you know, or so the theory goes, what value people place on their lives. Suppose that there is a 1 in 100,000 chance that an air bag in my car will save my life, and that I would pay $50 — but no more than that — for an air bag. Then it looks as if I value my life at $50 x 100,000, or $5 million.

    The theory sounds good, but in practice it has problems. We are not good at taking account of differences between very small risks, so if we are asked how much we would pay to reduce a risk of dying from 1 in 1,000,000 to 1 in 10,000,000, we may give the same answer as we would if asked how much we would pay to reduce the risk from 1 in 500,000 to 1 in 10,000,000. Hence multiplying what we would pay to reduce the risk of death by the reduction in risk lends an apparent mathematical precision to the outcome of the calculation — the supposed value of a human life — that our intuitive responses to the questions cannot support. Nevertheless this approach to setting a value on a human life is at least closer to what we really believe — and to what we should believe — than dramatic pronouncements about the infinite value of every human life, or the suggestion that we cannot distinguish between the value of a single human life and the value of a million human lives, or even of the rest of the world. Though such feel-good claims may have some symbolic value in particular circumstances, to take them seriously and apply them — for instance, by leaving it to chance whether we save one life or a billion — would be deeply unethical.

    Governments implicitly place a dollar value on a human life when they decide how much is to be spent on health care programs and how much on other public goods that are not directed toward saving lives. The task of health care bureaucrats is then to get the best value for the resources they have been allocated. It is the familiar comparative exercise of getting the most bang for your buck. Sometimes that can be relatively easy to decide. If two drugs offer the same benefits and have similar risks of side effects, but one is much more expensive than the other, only the cheaper one should be provided by the public health care program. That the benefits and the risks of side effects are similar is a scientific matter for experts to decide after calling for submissions and examining them. That is the bread-and-butter work of units like NICE. But the benefits may vary in ways that defy straightforward comparison. We need a common unit for measuring the goods achieved by health care. Since we are talking about comparing different goods, the choice of unit is not merely a scientific or economic question but an ethical one.

    As a first take, we might say that the good achieved by health care is the number of lives saved. But that is too crude. The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved, rather than simply the number of lives saved. If a teenager can be expected to live another 70 years, saving her life counts as a gain of 70 life-years, whereas if a person of 85 can be expected to live another 5 years, then saving the 85-year-old will count as a gain of only 5 life-years. That suggests that saving one teenager is equivalent to saving 14 85-year-olds. These are, of course, generic teenagers and generic 85-year-olds. It’s easy to say, “What if the teenager is a violent criminal and the 85-year-old is still working productively?” But just as emergency rooms should leave criminal justice to the courts and treat assailants and victims alike, so decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals.

    Health care does more than save lives: it also reduces pain and suffering. How can we compare saving a person’s life with, say, making it possible for someone who was confined to bed to return to an active life? We can elicit people’s values on that too. One common method is to describe medical conditions to people — let’s say being a quadriplegic — and tell them that they can choose between 10 years in that condition or some smaller number of years without it. If most would prefer, say, 10 years as a quadriplegic to 4 years of nondisabled life, but would choose 6 years of nondisabled life over 10 with quadriplegia, but have difficulty deciding between 5 years of nondisabled life or 10 years with quadriplegia, then they are, in effect, assessing life with quadriplegia as half as good as nondisabled life. (These are hypothetical figures, chosen to keep the math simple, and not based on any actual surveys.) If that judgment represents a rough average across the population, we might conclude that restoring to nondisabled life two people who would otherwise be quadriplegics is equivalent in value to saving the life of one person, provided the life expectancies of all involved are similar.

    This is the basis of the quality-adjusted life-year, or QALY, a unit designed to enable us to compare the benefits achieved by different forms of health care. The QALY has been used by economists working in health care for more than 30 years to compare the cost-effectiveness of a wide variety of medical procedures and, in some countries, as part of the process of deciding which medical treatments will be paid for with public money. If a reformed U.S. health care system explicitly accepted rationing, as I have argued it should, QALYs could play a similar role in the U.S.

    Some will object that this discriminates against people with disabilities. If we return to the hypothetical assumption that a year with quadriplegia is valued at only half as much as a year without it, then a treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends, for a similar period, the lives of quadriplegics. That clashes with the idea that all human lives are of equal value. The problem, however, does not lie with the concept of the quality-adjusted life-year, but with the judgment that, if faced with 10 years as a quadriplegic, one would prefer a shorter lifespan without a disability. Disability advocates might argue that such judgments, made by people without disabilities, merely reflect the ignorance and prejudice of people without disabilities when they think about people with disabilities. We should, they will very reasonably say, ask quadriplegics themselves to evaluate life with quadriplegia. If we do that, and we find that quadriplegics would not give up even one year of life as a quadriplegic in order to have their disability cured, then the QALY method does not justify giving preference to procedures that extend the lives of people without disabilities over procedures that extend the lives of people with disabilities.

    This method of preserving our belief that everyone has an equal right to life is, however, a double-edged sword. If life with quadriplegia is as good as life without it, there is no health benefit to be gained by curing it. That implication, no doubt, would have been vigorously rejected by someone like Christopher Reeve, who, after being paralyzed in an accident, campaigned for more research into ways of overcoming spinal-cord injuries. Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition.

    The QALY tells us to do what brings about the greatest health benefit, irrespective of where that benefit falls. Usually, for a given quantity of resources, we will do more good if we help those who are worst off, because they have the greatest unmet needs. But occasionally some conditions will be both very severe and very expensive to treat. A QALY approach may then lead us to give priority to helping others who are not so badly off and whose conditions are less expensive to treat. I don’t find it unfair to give the same weight to the interests of those who are well off as we give to those who are much worse off, but if there is a social consensus that we should give priority to those who are worse off, we can modify the QALY approach so that it gives greater weight to benefits that accrue to those who are, on the QALY scale, worse off than others.

    The QALY approach does not even try to measure the benefits that health care brings in addition to the improvement in health itself. Emotionally, we feel that the fact that Jack Rosser is the father of a young child makes a difference to the importance of extending his life, but his parental status is irrelevant to a QALY assessment of the health care gains that Sutent would bring him. Whether decisions about allocating health care resources should take such personal circumstances into account isn’t easy to decide. Not to do so makes the standard inflexible, but taking personal factors into account increases the scope for subjective — and prejudiced — judgments.

    The QALY is not a perfect measure of the good obtained by health care, but its defenders can support it in the same way that Winston Churchill defended democracy as a form of government: it is the worst method of allocating health care, except for all the others. If it isn’t possible to provide everyone with all beneficial treatments, what better way do we have of deciding what treatments people should get than by comparing the QALYs gained with the expense of the treatments?

    Will Americans allow their government, either directly or through an independent agency like NICE, to decide which treatments are sufficiently cost-effective to be provided at public expense and which are not? They might, under two conditions: first, that the option of private health insurance remains available, and second, that they are able to see, in their own pocket, the full cost of not rationing health care.

    Rationing public health care limits free choice if private health insurance is prohibited. But many countries combine free national health insurance with optional private insurance. Australia, where I’ve spent most of my life and raised a family, is one. The U.S. could do something similar. This would mean extending Medicare to the entire population, irrespective of age, but without Medicare’s current policy that allows doctors wide latitude in prescribing treatments for eligible patients. Instead, Medicare for All, as we might call it, should refuse to pay where the cost per QALY is extremely high. (On the other hand, Medicare for All would not require more than a token copayment for drugs that are cost-effective.) The extension of Medicare could be financed by a small income-tax levy, for those who pay income tax — in Australia the levy is 1.5 percent of taxable income. (There’s an extra 1 percent surcharge for those with high incomes and no private insurance. Those who earn too little to pay income tax would be carried at no cost to themselves.) Those who want to be sure of receiving every treatment that their own privately chosen physicians recommend, regardless of cost, would be free to opt out of Medicare for All as long as they can demonstrate that they have sufficient private health insurance to avoid becoming a burden on the community if they fall ill. Alternatively, they might remain in Medicare for All but take out supplementary insurance for health care that Medicare for All does not cover. Every American will have a right to a good standard of health care, but no one will have a right to unrationed health care. Those who opt for unrationed health care will know exactly how much it costs them.

    One final comment. It is common for opponents of health care rationing to point to Canada and Britain as examples of where we might end up if we get “socialized medicine.” On a blog on Fox News earlier this year, the conservative writer John Lott wrote, “Americans should ask Canadians and Brits — people who have long suffered from rationing — how happy they are with central government decisions on eliminating ‘unnecessary’ health care.” There is no particular reason that the United States should copy the British or Canadian forms of universal coverage, rather than one of the different arrangements that have developed in other industrialized nations, some of which may be better. But as it happens, last year the Gallup organization did ask Canadians and Brits, and people in many different countries, if they have confidence in “health care or medical systems” in their country. In Canada, 73 percent answered this question affirmatively. Coincidentally, an identical percentage of Britons gave the same answer. In the United States, despite spending much more, per person, on health care, the figure was only 56 percent.

    Peter Singer is professor of bioethics at Princeton University. He is also laureate professor at the University of Melbourne, in Australia. His most recent book is “The Life You Can Save: Acting Now to End World Poverty.”

    This article has been revised to reflect the following correction:

    Correction: July 19, 2009

    An article in The Times Magazine this weekend about the argument for rationing health care in the United States misstates the number of years it would take under the current system for the country to spend nearly a third of what it earns on health care. It is 26 years from now, or 2035, not 15 years.

  2. I remember reading a long time ago that some states in the US, including Oregon, already use this method when deciding on treatment. A panel decides whether to provide or deny treatment in cases where there is no possibility that the person will recover; their age is so advanced that any further treatment would have diminishing returns; or they have significantly and knowingly contributed to their health issue. The last was the most hotly debated, but in Oregon they decided that this was justifiable in order to provide universal care to all children and basic care for everyone regardless of their insurance. Do you know if this system still exists?

  3. Health care sustainability will require some rationing. In British Columbia over 40% of our provincial budget goes to health care. However, if we continue on the present course in a decade the Minister of Health projects that it will be 85% – leaving little else for education, roads, public transit and social assistance. Us boomers have led a charmed life which is not sustainable. Rationing health care to render it more sustainable is necessary to protect the other principles of universality and comprehensive and public.

  4. I don’t understand your attitude towards this at all. On the one hand, you say:

    “we need to make sure that the rationing is driven by intelligent considerations, rather than morally dubious ones such as the wealth of the person receiving treatment.”

    And then you say it is impossible to prevent the rich from buying expensive treatments for themselves. So, in fact, you are advocating health care rationing only for people who can’t afford to pay for their own health care. So, you’re advocating a two-tiered health care system. But, you just said that it was morally dubious that the wealth of a person determine whether they receive treatment?

    The reason for this divide between what you believe to be moral and what you advocate might be that health care rationing simply isn’t an ethical issue at all – it’s a question about the efficient distribution of resources, it’s a question about maximizing measurable outcomes, it’s in short not ethics but statistics – but, since Singer is a utilitarian he can’t see the difference between ethics and applied maths.

    The joke about the million-or-50 dollar prostitute is about as pathetic a philosophical “analysis” as I’ve ever seen. Any philosopher worth their salt knows that quantitative differences can be qualitative. In fact, Singer knows this because I know he studied Hegel in the 80s. But he chooses simply to ignore this crucial point (which applies exactly here – a million dollars and 50 dollars are qualitatively distinct amounts of money, the difference between them in the case of anyone other than the super-rich can not be understood as a difference of degree) because it serves his polemic purpose of turning ethics into a game of calculation.

    Now, of course I’m for the efficient distribution of resources. Who isn’t? What I’m not for is ignoring the fact that we turn health into a resource by considering it in a particular way, and this way of thinking about health is contingent. Neither do I think its a choice – and only if it were a choice whether or not to think of health care as a resource/product could that way of thinking about it be an ethical choice (only choices can be ethical choices). Rather, what I wish to assert, is that once health care has become a resource/product it is useless to go on thinking that its distribution is somehow an “ethical” issue. Ethical decisions concern persons, and there are no persons in health care – only objects (or more specifically, inputs and outputs). The fact we identify the outputs as being connected to persons is merely incidental, and is the cause of all this confusion and backlash against health care rationing.

  5. And then you say it is impossible to prevent the rich from buying expensive treatments for themselves. So, in fact, you are advocating health care rationing only for people who can’t afford to pay for their own health care.

    I do think it’s inevitable. Even if we banned all medical care paid out of pocket in Canada, people could always go to the US, or India, or Switzerland, or Saudi Arabia, or wherever.

    Practically, we cannot stop people from spending their own money on whatever treatments they like. What we can do – and need to do – is control expenditures related to treatment paid for by various forms of insurance. This includes private schemes, public schemes, and implicit public schemes like requiring emergency rooms to treat anyone who shows up.

  6. For practical reasons – and possible for ethical ones – we cannot really tell people not to ‘waste’ their money, especially if they are doing so on something as vital as healthcare. How can we allow people to buy yachts and BMWs, but not MRIs and heart surgery?

    Similarly, for both practical and ethical reasons, we need to avoid waste in situations where costs are borne collectively.

  7. “I do think it’s inevitable. Even if we banned all medical care paid out of pocket in Canada, people could always go to the US, or India, or Switzerland, or Saudi Arabia, or wherever.”

    Of course – but that doesn’t mean we shouldn’t ban it. If it’s bad, we should raise the cost of entry. In fact, it’s the same as counter fitting – we can’t outright ban counter fitting because people can still do it, but we can make it very difficult by making it illegal and making the currency expensive to duplicate. How is that any different from making it necessary to leave Canada to get the surgery (expensive), or even simply making it illegal to purchase such surgery abroad.

  8. Milan, I don’t understand your attitude towards this at all. On the one hand, you say:

    “we need to make sure that the rationing is driven by intelligent considerations, rather than morally dubious ones such as the wealth of the person receiving treatment.”

    And then you say it is impossible to prevent the rich from buying expensive treatments for themselves, and because its so impossible we shouldn’t try (are you advocating we get rid of existing legislation that attempts to prevent private health firms from coming into existence?). So, in fact, you are (are you?) advocating health care rationing only for people who can’t afford to pay for their own health care. So, you’re advocating (are you?) a two-tiered health care system. (Britain? Thatcher? That went well.) But, you just said that it was morally dubious that the wealth of a person determine whether they receive treatment? (You may not care about neo-liberalism, but neo-liberalism cares about you).

    The reason for this divide between what you believe to be moral and what you advocate might be that health care rationing simply isn’t an ethical issue at all – it’s a question about the efficient distribution of resources, it’s a question about maximizing measurable outcomes, it’s in short not ethics but statistics – but, since Singer is a utilitarian he can’t see the difference between ethics and applied maths. In other words, I don’t think you’re on the wrong side of some ethical dilemma – I think the ethical dilemma is only apparently a moral issue.

    The joke about the million-or-50 dollar prostitute is about as pathetic a philosophical “analysis” as I’ve ever seen. Any philosopher knows that apparent quantitative differences can in fact be qualitative. In fact, it would be quite rude of me to even imagine that Singer didn’t know this. But he chooses simply to ignore this crucial point (which applies exactly here – a million dollars and 50 dollars are qualitatively distinct amounts of money, the difference between them in the case of anyone other than the super-rich can not be understood as a difference of degree) because it serves his polemic purpose of turning ethics into a game of calculation.

    Now, of course I’m for the efficient distribution of resources. Who isn’t? What I’m not for is ignoring the fact that we turn health into a resource by considering it in a particular way, and this way of thinking about health is contingent. Neither do I think its a choice – and only if it were a choice whether or not to think of health care as a resource/product could that way of thinking about it be an ethical choice (only choices can be ethical choices). Rather, what I wish to assert, is that once health care has become a resource/product it is useless to go on thinking that its distribution is somehow an “ethical” issue. Ethical decisions concern persons, and there are no persons in health care – only objects (or more specifically, inputs and outputs). The fact we identify the outputs as being connected to persons is merely incidental, and is the cause of all this confusion and backlash against health care rationing. The Jewish teaching which equates the weight of a human life with all the world is an ethical teaching – but the idea that it somehow conflicts with health care rationing is as absurd as to say it immoral for a manager at McDonald’s making sure they don’t order the ingredients for too many fishwiches and too few big macs.

  9. So you think we need much harsher rationing than Singer proposes, extending even to how people can spend their own money.

    Why? Because you think the system will be better if rich people are forced to use it?

  10. Also, I think banning people from buying medical care abroad would be illegal. From the Charter of Rights and Freedoms:

    6. (1) Every citizen of Canada has the right to enter, remain in and leave Canada.

    To be legally meaningful, a right to leave Canada means a right to leave Canadian legal jurisdiction. It is the laws of the sovereign state you are in (including applicable international laws on things like piracy) that determine the legality of what you do there.

  11. Nobody’s Normal Anymore
    Should we blame overdiagnosis for rising health costs?
    By Darshak Sanghavi
    Posted Wednesday, July 22, 2009, at 11:56 AM ET

    My family’s overall health history—a collection of common problems punctuated by some rare ones—is fairly normative. And almost none of these conditions was widely diagnosed or treated a few decades ago; instead, many older women remained stooped, children grew up with delayed speech and chronic constipation, young mothers were told they were just tired and needed to stress less, some men were written off as senile, and many others lived sleeplessly and breathlessly.

    One must hesitate from drawing larger conclusions from one’s experience; after all, the plural of anecdote is not data. And one surely can argue there is a downside to modern health care. In an essay criticizing the “medicalization of everyday life,” several Dartmouth-based doctors pointed to an “epidemic of diagnoses” advanced by special-interest groups, which must be stopped. The typical solution to such medical waste (most recently described in a New York Times Magazine article by utilitarian ethicist Peter Singer) is to ration health care spending, often with dubious mathematical formulae—in short, to starve the beast.

    Unfortunately, these arguments rarely go beyond the broadest generalities. As I’ve argued, doctors certainly oversell the importance of some issues, like high cholesterol. But like many critics of modern medical care, the Dartmouth doctors see overdiagnosis everywhere they look and don’t reliably separate the wheat from the chaff. They derisively state that coughing children are too often labeled asthmatic; “twitchy legs” and “impaired sex drive” are inexplicably considered medical problems; those who can’t read are for some reason called dyslexic; those who are just sad are instead said to be depressed; and people with joint pain are termed arthritic. The subtext of their comments is, There’s nothing wrong with these people. Yet they’re still patients who can’t sleep, breathe, read, or enjoy sexual relations. They seek help, and it’s wrong to ignore them.

  12. “More importantly, that’s not even where the savings may be found. The highest yield and most reliable way of cutting health costs are obvious to most health economists. For example, David Cutler’s spending analysis clearly found that it costs far more to prolong the lives of the elderly ($145,000 per year gained) than the young ($31,600), and the rate of spending on the oldest Americans has grown the fastest.

    To be serious about cutting costs, then, we must forget about separating worthwhile from worthless diagnoses—a red herring. Instead, we need to bring down the health costs of the elderly, who are the budget busters of our health care system. This is precisely the hardest political battle to fight. (Consider the recent battles over the Bush administration’s resistance to expand the State Children’s Health Insurance Program, which concerned an amount of money that’s literally a decimal point rounding error of the Medicare budget.) “

  13. Tangentally this is interesting considering the opposition to US healthcare reform (specifically government interference) is already starting their propoganda, using a disgruntled Canadian to do so.

    I think our system already does this, or tries to, in assessing who gets what treatment, and when. As much as we hear about waiting lists, etc. having a terminal illness generally gets you to the front of the line, and our ERs operate on a triage model. That said we also have a “no patient left behind” philosophy, regardless of prognosis that flies in the face of utilitarianism. However, scarcity of resources or not, I can’t agree to not treat someone. Ethically you shouldn’t put a value on human life.

  14. I hate when Americans use Canada as an example to claim poor health care coverage, because the horror stories are anecdotal… you can find anecdotal evidence of a bad experience of anything anywhere.

  15. Ethically you shouldn’t put a value on human life.

    You cannot avoid doing so. Virtually any important public policy will affect how long and well at least some people live, whether it is welfare policy, engineering design standards, agricultural policy, etc.

    Both as individuals and a society, we need to make choices under conditions of scarcity. One such choice is deciding that a condition is not worth treating, or that a particular treatment is too expensive to justify.

  16. The cost we put on life isn’t always in money. Think about speed limits. If we only let people drive cars at less than 20km/h, far fewer people would die in collisions. The fact that we do not suggests that the costs associated with such a policy – costs to convenience, costs to commerce, costs to the auto industry – are too much to sacrifice in exchange for saving those lives.

    When it comes to health care, the challenge is to decide which treatments offer sufficiently great value to be worth providing. To me, it seems like the best way to measure that is in terms of how much they will extend a person’s life, coupled with how they will alter its quality.

  17. I don’t disagree with a prioritization of treatment. In Canada we do just that and sometimes hard choices are made, but the way we prioritize is different that the QALY method advocated by the article. In that if your illness is life-threatening and treatable, it will get treated. Our priority is based on illness severity only, not unlike the organ donor lists. If your prognosis is poor, you move up the list, if you can wait safely, you wait. No judgment is made on length of life afterwards, cost, etc…

    That said, I do suppose Ontario Health and other provinces have put limits on what is and isn’t covered, and in a round about way put a value on life, but most coverage limitations are not on life-threatening illnesses, but other non life-threatening ones, especially elective procedures, so they are not putting a value on life itself, but perhaps more on the quality of life to be enjoyed (a subtle difference).

  18. “Why? Because you think the system will be better if rich people are forced to use it?”

    What? “It’s better because the rich are forced to use it” is about the definition of the heath system we already have.

  19. “So you think we need much harsher rationing than Singer proposes, extending even to how people can spend their own money.”

    I don’t think I said anything about what we need. I said I don’t think this is a moral issue. It’s just an efficiency issue, no different from the owner of a hotel deciding how it should have its laundry dealt with.

  20. “The cost we put on life isn’t always in money.”

    That’s true – because money is exchange value, and not all costs are exchangable. In fact, very few costs are exchangable without some sort of idealization. But, the only way these costs can be expressed is in some universalized form of value, which then needs to be compared with exchange value. That’s what Singer is doing with quality of life adjusted years, and assigning them a price value.

  21. What? “It’s better because the rich are forced to use it” is about the definition of the heath system we already have.

    You can buy all sorts of private health care in Canada now: from private MRI clinics to private surgeons. Private health insurance (BLue Cross, Manulife, etc) is also available.

    To a moderate extent, we already have a two-tier health system.

  22. I said I don’t think this is a moral issue. It’s just an efficiency issue, no different from the owner of a hotel deciding how it should have its laundry dealt with.

    In life-and-death situations, ethics and ‘efficiency’ are pretty similar: better to have one person die in an accident than five; better to have 1,000 people die in a war than 1,500; better to have 50 people die waiting for surgery than 100.

    That being said, I think these are still ethical statements. You can only ever be efficient relative to some standard (energy use, cost, etc), and the standard being optimized for in calculations of this kind is human welfare, the best proxy for ethics we have.

  23. “better to have one person die in an accident than five”

    Sure, of course, no one disagrees that it isn’t “better” to have one person die in an accident rather than five. But that is no proof its an ethical issue. What does human welfare have to do with ethics? A good proportion of ethical “dilemmas” are just those cases where maximizing welfare isn’t the ethical thing to do (i.e. pleasure wizard, trolley problem, individual freedom to perform dangerous activities). So, why just assume maximizing welfare is ethics, and then there are some problems – rather than recognizing that maximizing welfare is just like maximizing profits – on its own logic desirable, but with no inherent connection to ethical considerations?

  24. “You can buy all sorts of private health care in Canada now: from private MRI clinics to private surgeons. Private health insurance (BLue Cross, Manulife, etc) is also available.”

    So, because we already have some two-tiered health care, there is no point in trying to avoid going down the British route of cutting back the public system to the point where anyone who can afford it buys private health insurance?

    Well, at least it keeps more accountants and advertisers employed.

  25. “better to have 50 people die waiting for surgery than 100.”

    Sure – because the value of life-saving is contained in the practice of surgery. But the fact that the value, the achievement of which is being maximized, is desirable simply on the basis of the practice is no guarantee ethics is around. I could as easily say “better to go around the Nurburgring (a racing track) in 8:32 rather than 8:50” – and the desirability of the faster time is simply contained in the practice of going around the track. But the fact the value of “faster” is contained in the practice of racing doesn’t make going faster a moral issue.

  26. You haven’t yet provided a clear account of why you think it is defensible and/or preferable to forbid people from spending their own money on their own health. Surely they already do in many ways: in everything from gym memberships to healthy food. Why is that permissible, but paying to see a doctor or surgeon is not?

    It seems like there must be a strong justification for curtailing liberty in such a critical area.

  27. I don’t think this discussion is worth much if it happens outside the context of the history of medicare, and in comparison to what happens in states who had a history of public medical care which was whittled away. I know this would sound strange coming only from me, but its too empty and theoretical.

  28. Also, in conformity with what I’ve said above, I never meant to imply it was morally justified to curtail freedom. I said, rather, that the providing of medical care is a technical problem, and whether it should be rationed is a technical solution, not a moral one – since it is concerned with outputs – not humans but properties of humans (QALY for example).

    The only moral question here is “is it right to consider health care like any other resource”? This is the question those who oppose health care rationing, such as the jewish priest in Singer’s article, vehemently answer “no” to. But, I don’t think that is a serious option today – notice in Singer’s article there is no argument to support the notion that health care is a resource, he simply asserts it. And, he’s not wrong for doing this – it’s hard to see what an argument would look like (i.e. how could it avoid begging the question, since saying something is a resource has to do with how we see it, not what it is). So, the only moral question isn’t really much of a question at all.

    The issue of the restriction of free economic activity concerning the purchase of health care resources, the question sure seems moral. But, It’s really just a question of whether we should be free to externalize costs – since a market based health care system is much less efficient than a state run single-provider model, the “freedom” to purchase your own health care is just the freedom to increase health care costs on everyone else. But if we’ve already decided that health care is a resource and QALY are the output, and maximizing it is what we’re interested in, then we’ve already decided to limit this economic “freedom”.

  29. This is an unusual sort of externality, given the element of compulsion.

    Picturing a single-payer system as being like a big club, it may benefit those inside for the club to have more members. Refusing to join may thus be a kind of ‘externality.’ That being said, it seems more like failing to provide a benefit, when you are capable of doing so, rather than actively causing a problem which it is in your power to avoid.

    It seems morally problematic to say that people must join clubs when their doing so would benefit others, regardless of their preferences or what would happen to them as a result.

  30. What is a benefit and what is actively causing a problem depends on the status quo. So, if the status quo is a big club which benefits everyone, and you leaving benefits you but hurts others, you are actively causing a problem.

    If you want to ignore the status quo, then what is a benefit and what is an active cause of a problem can’t be distinguished at all.

  31. Should we be able to opt out of police protection, because we shouldn’t be compelled to buy into a state-run service? No, because enforcing the peace is done much better by a single state run industry. Similarly, health is better cared for by a single state run industry. It’s just a question of efficiency. “Are you willing to give up efficiency for choice” is the only moral question here.

  32. I have studying certain areas of health care in Canada. In those areas, the public and private sector both deliver the services. The private delivers the services more efficiently. The public sector is burdened by maintaining jobs where technologies have made the number of those jobs redundant.

    One of the challenges for the efficient use of our public health care dollar is the strength of public sector unions. The public sector health care unions seems to have as a primary purpose protection of existing jobs rather than more efficient delivery of quality health care services. The patients as “consumers” are not at the bargaining table.

    To deny or question the patient “consumer” who chooses to use their dollar to pay for medical services outside of a public health care system does not seem fair.

  33. “To deny or question the patient “consumer” who chooses to use their dollar to pay for medical services outside of a public health care system does not seem fair.”

    The consumer is interested in what’s best for them. But, if what’s best for them is worse for others, then they are imposing a cost on others. It seems difficult to justify a change to the system which will make things worse for the least well off only on the basis that it increases the margin of choice of those well off enough to decide between private and public care.

  34. Wouldn’t you rather decisions about your medical treatment were made by government-paid medical experts, focused on which treatment may help you get better, than by private insurance companies focused on maximizing corporate profits? Granted, once a treatment is approved, the government would probably pay less for it than a private insurer would. But, ultimately, government is answerable to the public. Insurance companies are answerable to their stockholders.

    It’s a no-brainer for me and, I presume, for our president. But it is not a no-brainer for respondents to the Kaiser Family Foundation’s poll, as the accompanying pie chart demonstrates. A 45 percent plurality worries more that under health reform, “government agencies would play too big a role in deciding which medical procedures people can or can’t get,” while a 36 percent minority worries more that under the status quo, “insurance companies play too big a role in deciding what medical procedures people can or can’t get.” Twelve percent worry about both equally, while 7 percent worry about neither, don’t know, or don’t feel like answering the question.

    These findings may demonstrate a (nonmajority) preference for the devil you know. Or they may indicate that the conviction that “government is not the solution to our problem; government is the problem” did not die with Ronald Reagan, as a Rasmussen survey suggested at the height of September’s financial crisis. In that survey, 59 percent of voters—including 49 percent of Democrats and 44 percent of those who intended to vote for Barack Obama—supported the famous assertion in Reagan’s 1981 inaugural speech. It’s worth remembering that this poll was taken while an extremely unpopular president was presiding over the federal government.

  35. Examples of free market health care
    By Tyler Cowen on Medicine

    There are, however, no examples of successful health care based on the principles of the free market, for one simple reason: in health care, the free market just doesn’t work.

    That’s Paul Krugman. I would frame this point a little differently. There are in fact plenty of people who buy their health care in a more or less free market setting, most of all in Latin America but all over the world. It’s far from obvious that these markets fail in efficiency terms (“compared to what?” is the obvious follow-up). For the wealthy in Latin America these markets seem to work well. They work much less well for the poor but is that because of market failure or because these poor simply don’t have much money to spend?

    One possibility is that the main problem with these markets is distributional rather than efficiency. (Krugman’s third paragraph recognizes this, but he doesn’t use the point to reorganize the analytics of his critique. Also note some tricks. When markets fail at providing insurance, ex ante this is a possible efficiency problem but ex post it will be a problem of distribution.)

    Another way to state the health care problem is this: once we try to obtain distributional objectives, supply becomes less efficient. That understanding might focus your attention on a voucher-like system, combined with deregulation. rather than government interference in provision. Another option is for government to provide nudges to have better monitoring of HMOs or insurers, to make them more trustworthy. Or maybe catastrophic-only insurance, to overcome the distributional problem where it is most severe.

  36. Tristan

    My experience and comment did not relate to private insurance companies. Insurance companies do not provide medical services. Rather my experience and comment relates to medical services. It is also in the area of commodity service. I have found that the private sector has been more efficient in providing the services. The private sector is used to having to live within its means.

    Governments seem to be challenged in doing so, hence the practice of running deficits budgets. If the private sector can provide the service for half the price because it is twice as efficient, then there are more funds available for services including health care.

  37. Everyone here seems to agree that health care rationing is unavoidable and necessary. The disagreement is about who gets to ration, and on what terms.

    With Tristan’s extreme single payer system, government does all the rationing. In Canada’s real system, the government rations and people can ‘top up’ if willing and able. In a fully private system, rationing would be based only on what people were willing and able to pay.

    None of these systems seems likely to always produce good outcomes. Governments make foolish health choices, too. Just look at the pressure they come under to recommend meat and dairy in food guides, or ineffective efforts to deal with drug use and teenage sex by pushing abstinence.

    I can see why a single payer system is able to contain costs better, but I don’t see why allowing topping up automatically undermines it. As long as the government is making cost-effective choices, it doesn’t seem so problematic for people to be able to enhance the care they get with their own money.

  38. “Everyone here seems to agree that health care rationing is unavoidable and necessary. The disagreement is about who gets to ration, and on what terms.”

    Good, then there is no moral debate on whether we should ration or not. We simply all agree that it is better to ration more efficiently, and disagree about how. Just like various board members of Wal Mart might agree that efficient distribution is what they want, yet disagree about how to achieve the most efficient distribution system.

  39. I continue to be bewildered about how you can believe that this isn’t an ethical question.

    Old people are expensive to keep alive. Clearly, we cannot spend an infinite amount of money on care to extend their lives. That being said, it seems like the question of how much care they should receive is fundamentally an ethical one. It’s an optimization problem, perhaps, but what we are maximizing is welfare, goodness, or whatever you want to call it – an ethical quantity.

  40. Everyone here seems to agree that health care rationing is unavoidable and necessary.

    This is what makes it bewildering that people in the US think socialized medicine and ‘rationing’ are a terrible alternative future. They are (potentially misguided and) afraid of Tristan’s hard rationing option, not the Canada-style soft rationing that is probably the high water mark of what is possible in the US.

    There is no way Obama would try to create a law that forbids the private purchase of medical care, no way Congress would pass it, and no way US courts would let it stand.

  41. People in the US probably aren’t afraid of such a system, but people may be legitimately concerned about harsher rationing than they currently experience.

    If private health care plans needed to commit to a public one, they might stop paying for some experimental treatments in order to try to stay as profitable as before.

  42. That’s the real worry: not being prevented from paying out of pocket, but being obliged to for more things.

  43. Any time there is infinite demand for something finite, there will be some kind of rationing that emerges.

  44. Welfare, as such, is only a “moral quantity” if you’ve already decided ethics is just the maximization of a quantity. Some people think ethics is about the quality of actions, rather than the quantity of their outcomes. I’ve simply pointed out that if you insist ethics is about the maximisation of some quantity (utils?) then the only difference between ethics and any other kind of maximization is the output you maximise. But who gets to decide which output? There is much power in the right to decide it will be quantified in such and such a way (i.e. QALY’s), but that isn’t only what I mean – deciding the output is something like welfare in general already excepts actors from needing to examine the qualitative character of their decisions, can simply resort to numbers, facts, equations. Different from any other maximisation only in that this output is the “moral” one, and in no other way. Morality becomes a property of outputs, not actions.

    And, as soon as morality is not about actions, you can clearly see you’ve made a mis-step somewhere.

  45. Why You Can’t Trust Your Health Insurer
    Private insurance companies dump very sick claimants based on stupid technicalities. That’s reason enough to support health reform.
    By Timothy Noah
    Posted Monday, July 27, 2009, at 6:02 PM ET

    Blue Dog Democrats are (for reasons Steven Pearlstein of the Washington Post and Paul Krugman of the New York Times correctly label “muddled”) obstructing House passage of health care reform. The Congressional Budget Office says the White House’s “game-changing” proposal to create a Fed-like body to control Medicare costs will save only $2 billion over 10 years and may not save a dime. The Senate finance committee is still groping for a way to raise taxes to pay for a health reform bill it has yet to introduce. The Washington Post’s editorial page is chiding the president for neglecting to tell the elderly and infirm that they have a duty to die, as Colorado Gov. Dick Lamm famously suggested back in 1984. (Lamm—naughty fellow!—turns 74 next week.) In the New York Times, David Leonhardt poses the health-reform question of the hour: What’s in it for me?

    A comprehensive answer may be found in this excellent New York Times editorial. I’ll focus here more narrowly with a three-word answer: No more rescissions.

    Rescission (also known as “post-claims underwriting”) is the process whereby health insurers avoid paying out benefits to treat cancer and other serious illnesses by seeking and often finding chickenshit errors in the policyholder’s paperwork that can justify canceling the policy. In one job evaluation, the health insurer WellPoint actually scored a director of group underwriting on a scale of 1 to 5 based on the dollar amount she had managed to deny through rescission. (The director had saved the company nearly $10 million, earning a score of 3. WellPoint’s president, Brian A. Sassi, insists this is not routine company practice.) Rescission’s victims tend typically to be less-educated people who are more likely to make an error in filling out their insurance forms and lack the means to challenge a rescission in court—a path in which success is, at any rate, not guaranteed, because under state law the practice is perfectly legal if done within the allowable time frame (typically up to two years after a policy is issued).

  46. Editorial
    Health Care Reform and You

    Published: July 25, 2009

    The health care reform bills moving through Congress look as though they would do a good job of providing coverage for millions of uninsured Americans. But what would they do for the far greater number of people who already have insurance? As President Obama noted in his news conference last week, many of them are wondering: “What’s in this for me? How does my family stand to benefit from health insurance reform?”

    Many crucial decisions on coverage and financing have yet to be made, but the general direction of the legislation is clear enough to make some educated guesses about the likely winners and losers.

  47. The Health-Care Sacrifice
    What President Obama needs to tell the public about the cost of reform

    Sunday, July 26, 2009

    PRESIDENT OBAMA sometimes presents health-care reform as a pain-free proposition, as simple as choosing the red pill over the blue — one that’s no more effective but costs twice as much. Asked at his news conference whether “the American people are going to have to give anything up in order for this to happen,” Mr. Obama’s basic answer was no. “They’re going to have to give up paying for things that don’t make them healthier,” he said.

    This all-gain-no-pain stance may be politically advisable; people are increasingly edgy about how reform will affect their own health care. A new poll by the Kaiser Family Foundation shows that that the percentage of those who believe they will be worse off if reform passes (21 percent) has doubled since February.

    But Mr. Obama’s soothing bedside manner masks the reality that getting health costs under control will require making difficult choices about what procedures and medications to cover. It will require saying no, or having the patient pay more, at times when the extra expense is not justified by the marginal improvement in care. Mr. Obama is right that sticking with the status quo is a bad alternative, but he isn’t leveling about the consequences of change.

  48. The failure of market-driven medicine was foretold by the Nobel Prize-winning economist Kenneth Arrow in a 1963 paper (“Uncertainty and the Welfare Economics of Medical Care”) that is widely credited with inventing the discipline of health care economics. (In 1963, the health care sector was so sleepy financially and so dominated by nonprofit do-gooders that economists saw little reason to study it.) There were several factors making it difficult to impose a market model on medicine, Arrow wrote. Demand for services was “irregular and unpredictable,” and the buyer was physically vulnerable. Judging the value of the product (i.e., medical treatment) entailed a degree of uncertainty “perhaps more intense … than in any other important commodity,” which was compounded by the presumption of an extreme asymmetry between the doctor’s knowledge and the patient’s. Complicating matters even further, the patient didn’t pay; his insurance company did. The doctor “acts as a controlling agent on behalf of the insurance companies,” making sure the patient didn’t overuse his services, but only up to a point; “the physicians themselves are not under any control and it may be convenient for them or pleasing to their patients to prescribe more expensive medication, private nurses, more frequent treatments, and other marginal variations of care.”

  49. This letter to The Economist is interesting, though unrealistic:

    SIR – Regarding your special report on ageing populations (June 27th), I once proposed a solution somewhat tongue in cheek to the problem of pensions: turn retirement upside down. In my plan, people would be supported by society up to the age of 30. During that period they would study, travel, prepare for a profession, reproduce and give full-time care to their young. They would not hold any positions of responsibility, where their youthful enthusiasm, unbounded energy and over-ambition were likely to cause problems. After 30, they would work until they dropped dead or became incapacitated.

    The advantages are many. First, there would be more people working to support those young “retirees”. Second, social-security budgets could be prepared years in advance, and with greater certainty. Third, young “retirees” would need very little health care and the money saved could be spent on their education and child care. Fourth, individuals would enjoy life at the peak of their powers and give full attention to offspring. Fifth, no more bored and sick elderly people looked upon as useless.

    Cylon Gonçalves da Silva
    São Paulo

    Surely, the issues of demographic change, pensions, and healthcare are all deeply interrelated (along with those about population policies).

    The fact that people are now living so long beyond retirement age is going to prompt some significant changes in the structure of both the economy at large and government services particularly.

  50. The same debate referred to in your July 28 entry in the US will be and is occurring in Canada. Health care reform, in the form of heath care rationing to make the health care system fiscally sustainable will involve pain , or at least an acceptance that we cannot continue with the status quo.

    I was disappointed that Roy Romanow, who I admire, did not use his opportunity when looking at the health care system to begin that debate more seriously and earlier.

    Aging boomers with their increased expectations and pending retirements make the debate and action on health care rationing more pressing.

  51. Cost of Living
    Sarah Palin is afraid Obamacare will put a price on human life. But we already do.
    By Christopher Beam
    Posted Monday, Aug. 10, 2009, at 9:51 PM ET

    Conservatives often accuse liberals of not valuing human life. Rarely do they accuse them of valuing it too precisely.

    On Friday, Sarah Palin posted a statement on her Facebook page railing against the presidential “death panel,” which she said will decide whether you are “worthy of health care” based on your “productivity in society.” As many have pointed out, Palin’s concerns are not rooted in fact. The “death panel” she describes is a consultation that’s available to the elderly to discuss end-of-life care and treatment, which would be covered under health care reform. It would not be a thumbs-up or thumbs-down on whether your grandmother or disabled sibling lives or dies.

  52. This blog entry is timely. In British Columbia the heath authorities are considering ways to deal with the impending financial deficit. Two internal reports have been obtained by the media about some of the plans being considered by our two largest health authorities , Fraser Health and Vancouver Coastal, to reduce costs. These debates will continue as 40% of our provincial budget is on health care. The Health Minister states that if this is left unchecked, the heath care budget could go up to 85% in a decade, leaving very little for education, social assistance, roads, etc

    I find it ironic that we talk of health care when we are largely dealing with illness care. If we took better care of ourselves, the demand on health care services would be reduced. I read this week of a British survey which the chance of chronic illnesses such as Type II diabetes and chronic heart conditions were reduced by 78% in people that were not obese (BMI of less than 30), did not smoke, excercised (3.5 hours per week) and had a healthy diet. These are not revelations but also well-known. (and also remind me to try to bring my BMI down as it is unhealthy).

    We have not reached the stage where if someone has not taken care of themselves, health care will be limited. I hope we never reach that stage. However, it may occur.

  53. Apparently, BMI is a poor measure of whether someone is at an appropriate weight for their age, sex, height, and body type:

    Beyond BMI
    Why doctors won’t stop using an outdated measure for obesity.

  54. I think doctors realize that BMI is a poor measure for an individual. The heavily muscular fit athlete will have a higher BMI. However, BMI probably is a relatively good measure for epidemiologists and epidemiological studies.

  55. I also meant to add that BMI can also very easily be determined. You simply need someone’s weight and weight as opposed to the more accurate much harder to accomplish actual measuring of percentage of body fat.

  56. Congress Deadlocked Over How To Not Provide Health Care
    August 18, 2009 | Issue 45•34

    WASHINGTON—After months of committee meetings and hundreds of hours of heated debate, the United States Congress remained deadlocked this week over the best possible way to deny Americans health care.

    “Both parties understand that the current system is broken,” House Speaker Nancy Pelosi told reporters Monday. “But what we can’t seem to agree upon is how to best keep it broken, while still ensuring that no elected official takes any political risk whatsoever. It’s a very complicated issue.”

    “Ultimately, though, it’s our responsibility as lawmakers to put these differences aside and focus on refusing Americans the health care they deserve,” Pelosi added.

    The legislative stalemate largely stems from competing ideologies deeply rooted along party lines. Democrats want to create a government-run system for not providing health care, while Republicans say coverage is best denied by allowing private insurers to make it unaffordable for as many citizens as possible.

  57. The rationing canard

    “The deployment of scare quotes would seem to suggest that Mr Feldstein has a problem with the government limiting high cost, low-value treatments, even though they’re costly and not very valuable. In his third paragraph he says that Comparative Effectiveness Research—that is, research to determine whether treatments are effective or not—could lead to a cost-control mechanism which could become the vehicle for deciding whether a treatment’s effectiveness justifies its cost. And then he says something about a system that in no way resembles the one America would have if the current reform package passed. Left unaddressed is whether it counts as rationing if you’re still allowed to pay for additional services out of pocket.”

  58. Tonight, Jon Stewart interviewed a congresswoman concerning the “Suicide Panel” language in the health care bill. I don’t understand comedy central’s website, but if someone does, it would be good to link that interview here.

  59. China Admits Use of Death-Row Organs

    “Like a page from Larry Niven’s Known Space series, here is a real report of criminals’ organs being harvested for ‘profit.’ From the article: ‘China is trying to move away from the use of executed prisoners as the major source of organs for transplants. According to the China Daily newspaper, executed prisoners currently provide two-thirds of all transplant organs. The government is now launching a voluntary donation scheme, which it hopes will also curb the illegal trafficking in organs. But analysts say cultural bias against removing organs after death will make a voluntary scheme hard to implement.'”

  60. Lexington
    The politics of death

    Sep 3rd 2009
    From The Economist print edition
    Americans fear health reform because they fear the Reaper

    “Health reformers always smash up against two unpalatable truths. We are all going to die. And the demand for interventions that might postpone that day far outstrips the supply. No politician would be caught dead admitting this, of course: most promise that all will receive whatever is medically necessary. But what does that mean? Should doctors seek to save the largest number of lives, or the largest number of years of life? Even in America, resources are finite. No one doubts that $1,000 to save the life of a child is money well spent. But what about $1m to prolong a terminally ill patient’s painful life by a week? Also, who should pay?

    Few Americans have a clear idea how Obamacare will affect them—unsurprisingly, since even quite basic details are undecided. The uninsured have the most to gain, but they are only 15% of the population. Everyone else has something to lose. Many Americans do not trust the government to do anything much, let alone make decisions about life and death. Small wonder Mr Obama finds the headwind against health reform so blustery.”

  61. Op-Ed Contributor
    Big Food vs. Big Insurance

    Published: September 9, 2009

    TO listen to President Obama’s speech on Wednesday night, or to just about anyone else in the health care debate, you would think that the biggest problem with health care in America is the system itself — perverse incentives, inefficiencies, unnecessary tests and procedures, lack of competition, and greed.

    No one disputes that the $2.3 trillion we devote to the health care industry is often spent unwisely, but the fact that the United States spends twice as much per person as most European countries on health care can be substantially explained, as a study released last month says, by our being fatter. Even the most efficient health care system that the administration could hope to devise would still confront a rising tide of chronic disease linked to diet.

  62. The Case for Killing Granny
    Rethinking end-of-life care.

    My mother wanted to die, but the doctors wouldn’t let her. At least that’s the way it seemed to me as I stood by her bed in an intensive-care unit at a hospital in Hilton Head, S.C., five years ago. My mother was 79, a longtime smoker who was dying of emphysema. She knew that her quality of life was increasingly tethered to an oxygen tank, that she was losing her ability to get about, and that she was slowly drowning. The doctors at her bedside were recommending various tests and procedures to keep her alive, but my mother, with a certain firmness I recognized, said no. She seemed puzzled and a bit frustrated that she had to be so insistent on her own demise.

    The hospital at my mother’s assisted-living facility was sustained by Medicare, which pays by the procedure. I don’t think the doctors were trying to be greedy by pushing more treatments on my mother. That’s just the way the system works. The doctors were responding to the expectations of almost all patients. As a doctor friend of mine puts it, “Americans want the best, they want the latest, and they want it now.” We expect doctors to make heroic efforts—especially to save our lives and the lives of our loved ones.

    The idea that we might ration health care to seniors (or anyone else) is political anathema. Politicians do not dare breathe the R word, lest they be accused—however wrongly—of trying to pull the plug on Grandma. But the need to spend less money on the elderly at the end of life is the elephant in the room in the health-reform debate. Everyone sees it but no one wants to talk about it. At a more basic level, Americans are afraid not just of dying, but of talking and thinking about death. Until Americans learn to contemplate death as more than a scientific challenge to be overcome, our health-care system will remain unfixable.

    Compared with other Western countries, the United States has more health care—but, generally speaking, not better health care. There is no way we can get control of costs, which have grown by nearly 50 percent in the past decade, without finding a way to stop overtreating patients. In his address to Congress, President Obama spoke airily about reducing inefficiency, but he slid past the hard choices that will have to be made to stop health care from devouring ever-larger slices of the economy and tax dollar. A significant portion of the savings will have to come from the money we spend on seniors at the end of life because, as Willie Sutton explained about why he robbed banks, that’s where the money is.

  63. In short, the usual rules of the marketplace seem not to apply to health care. When left to their their own devices, buyers ignore product quality, fail to value goods properly, and overpay vast sums. (Weirdly enough, they’re also happy as clams with the results.) Yet every health reform bill with a chance of passing involves significant cost shifting to patients. Like it or not, patients will have to be better consumers. That’s why it’s critical now to fix the failures of the market before we throw open the gates for business.”

  64. Health Reform Winners and Losers
    How the House bill redistributes money to the middle class.
    By Timothy Noah
    Posted Tuesday, Oct. 6, 2009, at 5:44 PM ET

    “What we don’t hear much about is how health reform will take money from one group of people and give it to another. Some parts of health reform help people in all income groups—even millionaires worry that developing a chronic or fatal disease might imperil their insurability. But in general, health reform has a redistributive impact. Democrats hesitate to talk about this for fear of sounding like socialists. Republicans hesitate to talk about it for fear of sounding like plutocrats. But let’s face it: Redistributing income in one form or another is a very large part of what government does. Arguing about whether it should be done is like arguing about whether the sky should be blue. The more urgent question is how it is done.

    But in truth, the House health-reform bill is quite generous to the middle class—so generous, in fact, that the Tax Foundation purports to be scandalized. “Families in the middle of the income spectrum would benefit the most—an average of about $1,900 per family—from the greater income redistribution embedded in the House health reform plan,” says Tax Foundation President Scott Hodge in a press release. Who’s paying? Mostly people earning more than $358,000. That may outrage a few anti-redistributionist wonks on the right. But don’t expect to hear a lot of congressional Republicans bleat too openly about this, lest they alienate the party’s sizeable Glenn Beck/Rush Limbaugh wing. Glenn and Rush earn more than $350,000, but I doubt many of their followers do.”

  65. “The most reasonable assumption for Main Street is that health-care costs will either continue to grow at the same pace as for the past decade—or accelerate. This is a looming disaster for American business. The proportion of GDP devoted to health care has grown from 5% in 1962 to 16% today. Rising health-care costs appear to have suppressed wages, as firms seek to make up for the expense. America spends 53% more per head than the next most profligate country and almost two-and-a-half times the rich-country average. With health-care costs rising much faster than general inflation and 500,000 baby-boomers now becoming eligible for Medicaid every day, health-care spending is likely to hit 20% of GDP by 2017 and 25% by 2025.”

  66. “For the most part, the American health system is dominated by cream-skimming health insurers and the myriad “fee for service” providers they do business with, which drive up costs by charging high prices for piece work. KP’s business model integrates fixed-price health insurance with treatment at its own hospitals and clinics. This has led to big efficiency gains, making KP one of the cheapest health-care providers in most of the regional markets in which it competes. Thanks to Mr Obama’s reforms, over 30m Americans will enter the health-insurance market over the next few years—and KP’s low prices should make it a big beneficiary.

    Moreover, KP’s medical results are as good as its financial ones. By many clinical measurements, it is the best-performing health-care outfit in the regions it covers. The firm’s success obviously holds lessons for its American rivals, but given that KP serves some 8.6m patients—more than the population of Austria—and has come up with some world-beating innovations, Sir Richard believes that there is “much that Europe can learn too.””

  67. “You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world. Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society.

    When you are sick, this is what you want from medicine. When you are a taxpayer, this is what you want from medicine. And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either. There is always a velluvial matrix to know about.

    You are joining a special profession. Doctors and scientists, we are all in the survival business, but we are also in the mortality business. Our successes will always be restricted by the limits of knowledge and human capability, by the inevitability of suffering and death. Meaning comes from each of us finding ways to help people and communities make the most of what is known and cope with what is not.

    This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do.”

  68. “That leaves the third charge levied against Dr Berwick—that he will become America’s “rationer-in-chief” of medical care. This is a politically explosive claim: Americans do not like the sound of rationing. Indeed, the noisiest protests against Mr Obama’s reform efforts broke out last August when some Republicans, including Sarah Palin, claimed that “death panels” would eventually decide which sick people to kill off first to save money.

    Conservatives point to the doctor’s endorsements of Britain’s National Health Service, a government-run system that is called “socialism” in right-wing America. What this means, says Dr Barrasso, is that “Dr Berwick is a self-professed supporter of rationing health care.”

    That is true, but it obscures the larger point. Every health system rations in some way or other; the demand for health care is always greater than the resources available. The question is whether rationing is done openly and as sensibly as possible—or done implicitly, through murky pricing, bureaucratic fiat or denial of care.

    Even Paul Ryan, a leading Republican congressman, has acknowledged this. “Rationing happens today! The question is who will do it? The government? Or you, your doctor and your family?” he asks. The most objectionable aspect of Dr Berwick’s recess appointment is that Americans deserve a grown-up debate about this subject. It appears they will have to wait a bit longer for it.”

  69. Britain’s National Institute for Health and Clinical Excellence, a public body that judges whether medicine is cost-effective (ie, what Sarah Palin would call a “death panel”), has rejected several new cancer drugs. That so upset patients and tabloid editors that the British government back-tracked and created a separate fund to pay for expensive oncology drugs. The government now plans to introduce “value-based pricing” by 2014, with a system to price drugs not just for their efficacy but also for their “wider societal benefits”.

  70. Buttonwood
    The return of rationing
    The difficult decisions needed in an age of austerity

    POLICYMAKERS must juggle three priorities when offering a public service: coverage, cost and choice. They almost always have to sacrifice at least one of the three. As austerity bites, this equation is going to lead to very tricky decisions.

    Health is an area where the trilemma clearly applies. Britain’s National Health Service offers universal coverage but as a result has to limit patient choice in order to control the costs. The American health system historically gave a high priority to patient choice at the price of ballooning costs and the exclusion of the uninsured from the system. Having increased coverage, the Obama reforms will have to restrict choice if they are to control costs.

    Over the past 40 years cost has been less of a constraint in all areas of public policy than it might have been. At times of crisis governments without exchange-rate targets have been able to let their currency, rather than the real economy, take the strain. Steady growth has allowed governments to expand the services they offer. Once granted, a service or benefit is hard to remove because recipients campaign for its retention.

  71. Health care in Japan

    Not all smiles

    Japan’s health-care system is the envy of the world. It is also in crisis

    THE Japanese spend half as much on health care as do Americans, but still they live longer. Many give credit to their cheap and universal health insurance system, called kaihoken, which celebrates its 50th anniversary this year. Its virtues are legion. Japanese people see doctors twice as often as Europeans and take more life-prolonging and life-enhancing drugs. Rather than being pushed roughly out of hospital beds, they stay three times as long as the rich-world average. Life expectancy has risen from 52 in 1945 to 83 today. The country boasts one of the lowest infant-mortality rates in the world. Yet Japanese health-care costs are a mere 8.5% of GDP.

    Even so, the country’s medical system is embattled. Although it needs a growing workforce to pay the bills, Japan is ageing and its population is shrinking. Since kaihoken was established in 1961, the proportion of people over 65 has quadrupled, to 23%; by 2050 it will be two-fifths of a population that will have fallen by 30m, to under 100m. “The Japanese health system that had worked in the past has begun to fail,” Kenji Shibuya of the University of Tokyo and other experts write in a new issue of the Lancet, a British medical journal, devoted to kaihoken. “The system’s inefficiencies could be tolerated in a period of high growth, but not in today’s climate of economic stagnation.”

  72. “Dr. Ken Murray, a Clinical Assistant Professor of Family Medicine at USC, writes that doctors don’t die like the rest of us. What’s unusual about doctors is not how much treatment they get when faced with death themselves, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves because they know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. ‘Almost all medical professionals have seen what we call “futile care” being performed on people,’ writes Murray. ‘What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.”‘ Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming.”

  73. Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

    Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

  74. ASKED where they would like to spend their last days, Americans almost always say at home, surrounded by people they love. In real life, though, only one in five achieves that. More than 30% die in a nursing home, where almost no one wants to be, and over half end up in a hospital, often in an intensive-care unit, heavily sedated and attached to life-saving equipment until their doctors give up the battle.

    Death is a difficult subject for anyone, but Americans want to talk about it less than most. They have a cultural expectation that whatever may be wrong with them, it can be fixed with the right treatment, and if the first doctor does not offer it they may seek a second, third or fourth opinion. Litigation is a constant threat, so even if a patient is very ill and likely to die, doctors and hospitals will still persist with aggressive treatment, paid for by the insurer or, for the elderly, by Medicare. That is one reason why America spends 18% of its GDP on health care, the highest proportion in the world.

    Nor is it easy to decide when to stop making every effort to save someone’s life and allow them to die gently. The book quotes the case of one HIV-positive young man who was acutely ill with multiple infections. He spent over four months in hospital, much of the time on a ventilator, and had countless tests, scans and other interventions. The total bill came to over $1m. He came close to death many times, but eventually pulled through and has now returned to a normal life. It is an uplifting story, but such an outcome is very rare.

  75. Evaluating medical treatments
    Evidence, shmevidence
    The philosophical error that plagues American health care

    Jun 16th 2012 | NEW YORK | from the print edition

    TO SUGGEST curbing an American’s health care is like threatening to kidnap his child. More care, he believes, must be better care. On Mr Obama’s watch new attempts have been made to weigh evidence for different treatments. But the notion that evidence might be used to limit care remains heretical.

    To an outsider, it might seem helpful to know which services are worthwhile. America, after all, spends 18% of its GDP on health, far more than other rich countries. About one-third of that spending is waste. But America has a unique distaste for evidence. Most other rich countries have a formal way to judge the efficacy of different treatments. Britain has the strictest system. There the National Institute for Health and Clinical Excellence (NICE) judges the worth of new drugs and procedures. If the agency favours a treatment, the National Health Service will pay for it. If the agency does not, patients must pay for it themselves. Such a system makes American politicians shudder.

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