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Rationed Care, Denied Treatment, And “Death Panels”

One of the canards slung at the Affordable Care Act is that it creates “death panels” that would allow the government to deny patients lifesaving treatments, even though two independent and non-partisan fact-checking organizations found it would do no such thing.

I don’t bring this up now to rehash the debate, but because the New York Times had a recent story on Arizona’s decision to deny certain transplants to Medicaid enrollees — “death by budget cuts” in the words of reporter Marc Lacey. His story profiles several patients who died when they were unable to raise money on their own to fund a transplant. Lacey quotes a physician expert on transplants who flatly states: “There’s no doubt that people aren’t going to make it because of this decision.”

Arizona Medicaid officials told the Times that they “recommended discontinuing some transplants only after assessing the success rates for previous patients. Among the discontinued procedures are lung transplants, liver transplants for hepatitis C patients and some bone marrow and pancreas transplants, which altogether would save the state about $4.5 million a year.”

Lacey writes that the state based its decision on

“analysis . . . of the transplants that were cut, which many health experts now say was seriously flawed. For instance, the state said that 13 of 14 patients under the state’s health system who received bone marrow transplants from nonrelatives over a two-year period died within six months. But outside specialists said the success rates were considerably higher, particularly for leukemia patients in their first remission.”

As a non-clinician myself, I don’t feel qualified to express an opinion on whether the evidence supports the efficacy of transplants for patients with these conditions. But if you take Arizona Medicaid officials at their word, Arizona is making decisions based on the expected quality and longevity of life that may result from a given intervention and the cost of that intervention. Isn’t this the kind of “rationing” that critics of “government-run” health care rail against, only in this case it is a conservative-run state governor and legislature that is implementing such restrictions to save the state’s taxpayers some money?

Transplants, because the demand will always exceed the supply, have always been rationed based on medical criteria, although Arizona is taking it to a different level by explicitly taking cost into account.

The problem with Arizona’s approach is that the impact will fall disproportionately hard on the state’s poor. They don’t have access to private health insurance coverage that includes transplants and they don’t have the resources to fund transplants on their own.

The larger point is that the United States already limits access to health care, as all countries must do — because it isn’t possible for everyone to get everything they want or need. There is a superb discussion of this point in the November 24 issue of JAMA. Drs. Meltzer and Detsky write:

“Rationing already takes place [in the United States] in many ways in health care. Managed care is exactly a form of rationing in which a private insurer determines whether patients should or should not receive services. In addition, private sector rationing injects profit motives into the calculations. . . It is critical that Americans learn that rationing currently exists and is inevitable and focus their thinking on how its vagaries are best minimized, rather than use the word to instill fear.”

Tossing around words like “death panels” and “death by budget cuts” instills fear, when what we need is a reasoned discussion of how finite health care resources should be allocated equitably and rationally, and by whom — not just in Arizona, but throughout the United States.

Today’s questions: What is your reaction to Arizona’s decision to deny coverage for some transplants? Do you agree that all countries, including the U.S., ration care in some manner, and if so, is there a better way?

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*


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One Response to “Rationed Care, Denied Treatment, And “Death Panels””

  1. That the concept of “death panels” gets any amount of attention speaks to the ignorance of those who fear them. in reality, only a small few among us has any ability to cover whatever health costs come in our direction. As any resource is finite, so is health care and each of us must begin to think of these resources like life rafts on an overcrowded sinking ship. At some point, decisions have to be made how to best use the resources to save as many people as possible. Sadly, too many of us are unable or unwilling to grasp this idea.

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