I don’t disagree with the principle of allocating resources sensibly, of course that’s true. It’s just a question of addressing problems in the order of importance, in both an economic and ethical sense.
In any medical system - capitalist, UHC and every other variant - there are “cost/benefit analyses” going on. Resources are always limited, and sometimes those that are unfortunate enough to be outliers draw the short straw. Even on the NHS, which does a pretty good job of prioritizing both by individual medical necessity and to achieve the best overall outcomes, occasionally gets cases where individuals suffer from conditions that can only be addressed by treatments that are excessively expensive (like in the hundreds of thousands of pounds), highly speculative, or both, and the NHS has to draw a line there. And while they don’t automatically and cavalierly write off the elderly, if you’re 87 and need a liver transplant you’re probably not going to be as high on the recipient list as a 37-year-old needing a new liver.
There’s no perfect system. But the US system is really fucking flawed.
Yeah and the under 65 medical system is especially messed up. Medicare does work better than that.
I think there is more of this going on than is talked about because not everyone leaves a note explaining the medical expense conundrum. Our legislature can put a stop to it. Disgusted that they won’t.
I’ve written to Susan DelBene (D-WA, my representative).
Awesome. More of this, everyone.
Lots of people agree. My mother’s doctor has talked to her about the possibility of getting a kidney transplant if her kidney disease progresses. And she said, “no, that’s a bad use of resources. I’m old and have other health issues. It’s not responsible to expend that sort of resource on me.”
I don’t know how common that sentiment is among people who are actually looking death in the eye.
Not knowing your mother or her situation, she may actually be making the right decision for her. Most laypeople do not realize that a huge percentage of organ transplant recipients remain chronically ill, just in a different way than they were before.
My aunt, who had a genetic kidney disease that she passed on to her son (IDK what it’s called) was briefly on the transplant list at about age 70, and taken off because it was determined that her overall health had deteriorated beyond a point where she would have benefited from a transplant. My cousin did receive a transplant from my uncle about 10 years ago, and in the meantime developed a type of lymphoma that only occurs in immune-suppressed people, and his doctors have already told him that there’s a very real possibility that his 80-year-old kidney will fail in the coming years, and he will need to be re-transplanted.
As for insulin, I’ll never forget the first time I rang it up. I was a 16-year-old Target cashier in 1980, and thought there had to be some kind of mistake because there was just no way something this important could cost $6.28. It would have been the old animal-sourced insulin (beef or pork; fish insulin has also been used in Asia) and even though I was years away from deciding I wanted to be a pharmacist, I did know what it was. More recently, ca. 2000, when I worked at the grocery store, Humulin was about $20 a vial, and when people paid cash, we charged cost plus $1. (This was most commonly done by people who were buying it for their pets.)
When I heard of Humulin, I asked if they took pancreases out of dead people and extracted the insulin (I knew they used to do that with pituitary glands and growth hormone) and was told no, that a gene for human insulin was inserted into a special strain of E. coli bacteria, which then cranked out as much as they needed.
Animal insulins were phased out in the U.S. in the 1990s, much to the chagrin of many diabetics who had used it without issues for decades.
If that’s the case, Humulin should be dirt cheap. Believe me, it’s not.
In Spain a few years ago the figure of “domestic violence” was removed from the books and replaced by “gender violence”. There is currently a case in the courts* where a man who had just been diagnosed with dementia and who cared for his demented wife and her demented parents killed all four: the gender-violence courts want the case, the government’s attorney says it shouldn’t be called gender-violence, since gender is clearly not any kind of root cause of it (it’s not “I killed her cos she was mine”). That a murder happened in the house doesn’t necessarily qualify it as domestic or, using the current Spanish parlance, that it was a man on a woman as gender-triggered (never mind that the gender court is forgetting about the in-laws completely: what, they were flowerpots?).
- That probably nobody will ever be tried doesn’t mean there is no need to investigate. One of the main purposes of these judicial investigations is to figure out what went wrong, what failed, so that preventive measures can be put in place. For cases like this, what should be put in place: a better social safety network for ill people, or violence-prevention education?
In what world is mid-70s not ancient?
The rest of what you say is how medical care works in any healthcare system. There isn’t endless money. But in most of the developed world that means saying - in very, very toned down words - “I’m sorry, you’re 75 and chemo would make your remaining years terrible while costing the health service lots of money.” Not “no insulin for you, povo!”
In the UK, if someone in their 70s killed their partner and themselves, citing medical bills, it would be a straightforward case of murder-suicide because there wouldn’t be any medical bills.
I don’t know either. I sure hear much more frequently of ridiculous amounts of care being provided to someone who is already quite decrepit and dies soon despite the care provided.
You and your mom have way too much on your minds for my opinion to matter to you, but I want you to know that her attitude impresses the hell out of me.
I was trying to appear reasonable, by suggesting I was only speaking of REALLY old people. My personal thought is that if you make it to your mid-70s in somewhat decent health, you’ve had a pretty good run.
Today, I think average life expectancy in US/Caanada/England is around 78-82 years. But if you have made it to 60, I believe it is well into the 80s. When my parents died at 76 and 78, I felt they died too young. My MIL made it to her mid-80s, and FIL is 90 (too damned mean to die!)
Another prime example of this was the law that insurers had to spend 80% ( or was it 85%) of what they collected in premiums towards actual healthcare expenses.
This law lead to increased prices across the industry. Because it turns out that the insurers don’t have a lot of incentive to haggle with their suppliers if they don’t get to keep their savings.
And while I am HIGHLY critical of the pharmaceutical industry, it don’t think they are evil price gougers cackling insanely while killing people. (And I don’t call them Big Pharma). And I think dismissing legitimate criticism as a liberal meme only serves to make the situation worse. It’s denial of a real and serious set of problems.
They are a business. They are doing what businesses do. They are developing products and trying to get those products consumed by as many people as possible. They are developing pricing and marketing strategies to make as much money off these products as possible. They are lobbying for laws that will make it easier for them to accomplish these goals
Even though I’m liberal, I’m a capitalist and a successful business owner. I generally believe in these principles. But the biggest problem here is that the products aren’t iPhones, they include powerful psychiatric medications and highly addictive drugs with serious side effects. And the constant push to expand the customer base for these products has the potential to cause great personal and societal harm.
(There are other problems with the industry such as the widespread use and acceptance of surrogate endpoints leading to drugs that reduce a “number” or shrink a tumor without providing any evidence that the drug action confers a benefit to survival or quality of life, but that’s for another discussion.)
And when you combine the pharmaceutical industry with the insurance based healthcare system, you end up with a massive free market distortion where there is no force applying any downward pressures on pricing.
The patients, if insured, are paying a flat rate per month and have little incentive to be cost conscious regarding individual items. And any attempt to control costs by the entity that’s actually paying the bill makes them the bad guy.
For example, many insurance companies require that patients try a 30 day course of an older cheaper drug before they will pay for an ultra-expensive version that is virtually identical except for a few insignificant molecular tweaks. Now I think this is a perfectly reasonable policy in most cases. And I bet that any patient forced to make a rational economic decision between a drug that costs $30 a month and a drug that costs $3000 a month would agree to that condition if they were paying the bill themselves.
But this policy is wildly vilified.
Several years ago, 3 doctors at Sloan-Kettering refused to add a drug to their formulary because they did not feel the benefits it conferred were worth the outrageous financial cost. This was a bold move that I truly hoped would catch on, but unfortunately it didn’t. I think they did succeed in getting the prices lowered for that particular drug that one time, though.
The medical industry has conditioned us well. We are taught to demand the best and most expensive treatments for even the most minor conditions. And if you don’t think anything is wrong with you, there will be always be a TV commercial or industry funded “awareness campaign” to convince you otherwise.
Then once we are at the doctor, we have been conditioned that it’s wrong to bring financial considerations into the picture. We are used to be overdiagnosed, overtreated and overmedicated. And unfortunately, it’s going to be hard to change that norm.
But I do think the whole system needs an overhaul and that any discussion of health care reform has to be more than playing hot potato with the bill. And I don’t see that happening.
Oh, man, I saw so much of that when I worked in hospitals! Most of the time, it wasn’t even the patient’s decision, but rather that of ONE RELATIVE, usually a child but sometimes a sibling who showed little interest until the very end and swooped in to make all the decisions, who was in massive denial and couldn’t let go.
This is not the same as, for instance, not shutting off life support until all the children have arrived.
I think this is an excellent post.
What you’re describing about people blaming drug companies is analogous to people blaming evil bankers for the 2008 financial crisis. Now, it may well be true that some bankers and drug companies are evil. But nothing should depend on this. What we need in both banking and healthcare is sensible government policies to organize and regulate the free market so that it operates in the public interest. All that we should then require of profit-oriented participants in the free market is that they follow the law in competing with one another. The public interest should not depend on their goodwill. If it does, the legal and regulatory framework is not fit for purpose.
I don’t know how common it is, either; but I’ve known a number of people who reached a point at which they declined further treatment, even though it was available to them. Their motivations may not have all been about use of resources; but some people who are dying reach a point at which they’re ready to go – and not necessarily because they’re in any acute distress.
In a world in which in some families living into the 90’s isn’t unusual, and an increasing number of people break 100, some of them still in good enough shape to be enjoying it and to be benefitting other people’s lives?
Some people are ancient in their mid-70’s, yes. Not everybody is.
I’ll be 74 in several weeks. My health is far from great, but I’m certainly not anywhere near “ancient”.
In many cases, resources have nothing to do with it; they feel that they have just plain old lived long enough and in many cases, treatment of their illnesses may have reached a futile stage and they want to depart before their QOL declines any further.
There’s a story going bacterial on Facebook about a 90-year-old woman who found out she had cancer, and she declined chemo and decided to go on a road trip with her dog. I’m not sure if the story is real, but there are very few situations where anyone would give chemo, at least the standard therapies, to a 90-year-old. Jimmy Carter received a targeted therapy, not really a “drug” but a biological which was the right one for him.
The problem here occurs when the patient has done the $30 a month drug and had severe problems with it, then goes on to the more expensive drug.
Then has a new insurance provider, maybe because the person changed jobs or because the person’s company has changed insurance providers. And the new insurance company insists on the 30-day course of the cheaper drug, even though the patient had a bad reaction to it before, or it just doesn’t do what the patient needs it to do.