Today I got to hear former Colorado Governor Richard Lamm speak on healthcare. He's now a professor at University of Denver (alma mater of both Condoleeza Rice and Madeleine Albright). He made some news a few years back by saying that the elderly had "a duty to die". He's long spoken about resource allocation in healthcare - a topic few can get excited about without some catchphrase. His own father is 97 years old and doing pretty well. I have learned from sources I may not disclose that Governor Lamm is a devoted son who looks after his father commendably, so he shouldn't be taken as trying to implement Logan's Run.

Lamm said several things with which I disagree and some that were perfectly reasonable, but everything was thought through relatively well. Unfortunately in many ways Lamm's speech was a decade or more out-of-date.

Lamm noted the unsustainable rate of growth in healthcare spending without noting the success that managed care has had in reducing that growth.

Surprisingly for a Democrat, he admitted that the New Deal and Great Society programs were built on demographic assumptions that are no longer true, pointing out both the increase in life expectancy and the plummeting birthrate as causes. He noted that, while he disagreed with the President's proposed changes to Social Security, that program must change to survive.

While he noted that the large increase in life expectancy pre-dated the massive increase in healthcare expenditures, he didn't explicitly recognize the logical necessity of that situation. In the 19th century, many people died at early ages from things like cholera and typhoid that were prevented quite cheaply. Those folks started living to much older ages at which they started contracting diseases that are more difficult to prevent and quite expensive to treat - like heart disease and cancer.

He admitted that hard cases make bad policy and that we need to look at the big picture when making decisions on public health questions, citing the Coby Howard furor a few years ago when Oregon Medicaid denied a bone marrow transplant to a child with leukemia who ended up dying. In the wake of that furor, California mandated Medicaid coverage for organ transplants. The shifting budget priorities caused large cutbacks to prenatal care. In the first year after the cutbacks, the deaths of six
pregnant women and their babies who would have been eligible for prenatal care prior to the reprioritization were attributed to the lack of prenatal care. (He didn't mention if any study was done on how many other babies were killed by this policy, I'm sure there were very many babies so killed and little, if anything, done to find out how many.)

He mentioned that there is always some degree of rationing in healthcare, the larger question being who makes the rationing decisions and on what basis. He suggested that the patient's behavior be taken into account - i.e. no liver transplants for someone who is likely to continue to drink alcohol or no major treatment at all for recalcitrant smokers.

NB: I work in the business office of a small non-profit hospital. We do large amounts of charity care. In fact, our combined charity care, indigent care and Medicaid as a percent of the care we provide is higher than that of any other private hospital in the state (and public hospitals get paid more for indigent care than we do). We also have large amounts of uncollectible debt from "the uninsured". I've worked in healthcare for over ten years now both for providers and payers.

The rationing debate is one that will pick up steam in the years to come. It's the standards that are the real battleground.

Thought one: if part of the problem is a low birthrate, shouldn't there be financial disincentives to procedures and products that diminish the likelihood of healthy full-term pregnancies? (And would any political party be bold enough to suggest such a thing?)

Thought two: right now as a society we are doing quite a bit to shift some cost to the patient for those who have commercial insurance and those who are covered by governmental programs via increased deductibles, copayments and the like, we hear all sorts of campaigns to increase various forms of care at no cost to the patient. If a degree of patient responsibility is a good thing (and you'd have a hard time arguing that it isn't as there is no limit to the demand for care provided at no cost to the patient), then shouldn't we try to apply that principle broadly?