Rationing Issues | |
Organ Transplants, Designer Drug Therapy, and Other Life Saving but Expensive Medical Technologies
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One of the strangest features of health care politics is the inordinate effort to force health insurers to cover items that most people can afford to pay for out-of-pocket (for example, mammograms and pap smears) and the lack of attention to coverage for inordinately expensive, lifesaving technologies that few could pay for out-of-pocket. To the degree that there has been any real discussion of organ transplants, for example, the focus has not been on the need to insure for such procedures but on how to decide, bureaucratically, who among the uninsured will get transplants. Most people are probably not insured for organ transplants. Yet, as Table I shows, if the need arose most people would find it difficult to pay for one. Although we frequently hear that the constraint on transplants is a lack of donors (see Table II), an additional constraint is money. Kidney transplants are less expensive and usually paid for by government. Other transplants often must be paid for with private funds. In addition to organ transplants, other emerging technologies have great promise but will be very costly. One of the most intriguing is "designer drugs." These drugs are tailor-made for a specific patient, based on the patient's DNA makeup. In the future, undoubtedly there will be other technologies that promise to save lives but carry price tags far beyond the financial means of most people. The most common "solutions" to this problem fall into two camps: those to get government to fund expensive procedures that hospitals are already performing and want to perform more of, and those to set up rationing committees to determine which uninsured patients receive the treatment. The focus of the proposals, however, is on institutions and the money they will have to spend, not on patients and their preferences. Rarely is it suggested that a patient should be able to choose between having an expensive procedure done or keeping the money to spend for some other purpose. In an ideal health care system, insurers would have incentives to develop policies anticipating new technologies and helping people insure for them. New, lifesaving, expensive technologies are viewed as the enemy of today's health insurers, who often refuse to pay on the grounds that treatments are experimental, sometimes even after they have been proved effective. However if health insurers get out of the business of buying health care, and back with the business of insurance they will see new technologies as a reason why policyholders should buy more insurance, so they can afford the technologies if needed. |
NATIONAL WAITING LIST FOR ORGAN TRANSPLANTS |
The Clinton administration is about to dismantle the regional system
for distributing donated organs for transplants and replace it with a national
list on which, they say, the sickest patients would get priority. Smaller transplant centers fearing that a national list could put them
out of business. Big hospitals complain that their smaller counterparts
are trying to hoard organs for patients who are not desperate. Transplant
operations are a lucrative business, with some costing as much as $250,000. Some experts warn that awarding organs to the sickest patients may not
be good policy, since the sickest are more likely to die after their transplant
-- or need a second or third organ. Studies differ on how successful the proposed policy would be. One study
claims it would save as many as 200 lives a year, while another predicts
it would result in 761 additional repeat transplants annually. Moreover,
it says that the overall survival rate after transplants would drop from
75 percent to 68 percent. At present, the United Network for Organ Sharing, a nonprofit organization,
runs the distribution system. Here's how the system operates:
The administration's move has reportedly introduced even greater uncertainty
into the lives of those waiting for scarce suitable organs. Livers, in particular,
are in extremely short supply -- with 10,000 patients vying for the 4,000
available every year. Source: Sheryl Gay Stolberg, "Patients' Lives on the Line in Battle
over Transplants," New York Times, March 25, 1998. |
GOVERNMENT POLICIES CREATE ORGAN SHORTAGES |
A market-oriented approach to making human organs available for transplants
would increase their supply, some observers contend. At present the number
of people needing organ transplants far exceeds the available supply. That
is largely due to federal policies based on the premise that human organs
should not be bought and sold, critics say. Critics warn that this is dangerous public policy, since the sicker a
recipient is, the worse the chances the operation will succeed. Seriously
ill patients have at times needed a second transplant when the first one
failed -- thereby using up more scarce organs. Competition for organs between smaller, local transplant centers and
big-city hospitals is so fierce that local centers sometimes delay reporting
availability until it is too late for an organ to be shipped out. Critics
of the new policy expect that practice to increase under a fully nationalized
system. Right now, two-thirds of those on the waiting list need kidneys. Nearly
30 percent of the 11,000 kidney transplants performed in 1996 were from
live donors. Those who advocate applying a market approach to the system point out
that it would not only increase the supply of kidneys from the dead, but
induce healthy individuals to sell one of their kidneys. Moreover, such a policy would eliminate many of the conflicts and problems
that plague the present system. Source: Richard A. Epstein (University of Chicago Law School), "Sell
Your Body, Save a Life," Wall Street Journal, April 16, 1998. |
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