Tough Choices by Pat Conrad MD

The hilariously named Affordable Care Act is working exactly as intended.  It is collapsing, leaving an even worse sinkhole into which a fearful public, hyperventilated celebrity/media class, and gullible Republicans are diving.   We are – and I really hope I’m wrong – accelerating toward the dreamed of/dreaded “single-payer” system.  I’m not wrong.

We couldn’t afford the ACA.  We can’t afford the replacement AHCA even if it gets passed.  The states cannot afford Medicaid and its ever-expanding rolls.  We never could afford Medicare, even before the Baby Boomers began to belly up to the trough.

When sitting around with family, friends, or coworkers and this topic comes up, someone will often bring up single-payer, and how wonderful it was in this or that country they lived in for a couple of years.  I hear plenty of arguments that health care is a right, and that if you the taxpayer don’t provide a basic level of care, then there will be “people dying in the streets,” which is to say, you killed them.  I’m told that I can’t disallow this person, or that, for respectively good reasons.  So we don’t say “no” to anyone?

I don’t like the intellectual dishonesty in our profession, and the ignorance of the lay public that claims we can do it all for all, and a mythical “somebody” needs to settle the bill.  So let’s do a little thought experiment, and here is the premise:  you cannot afford to do everything for everyone, not even if you confiscate all the wealth from all the wealthy, and raze Wall Street.  Unrestrained demand will continue to lead to shortages, which will lead to rationing.  If you don’t accept this premise, then you are as loopy as a moon bat drinking fermented papaya juice, and there is no point in arguing with you.

If you do accept this premise, then *POOF*, you now have single-payer.

Consider the following patients:

  1. 60-year-old female with end-stage COPD.
  2. 27-gestational week preemie male.
  3. 45 year-old non-compliant male with uncontrolled Type II diabetes, hyperlipidemia, and multi-vessel coronary disease, recurrently admitted for chest pain.
  4. 26 year-old female graduate student, otherwise healthy, with a positive PAP.
  5. 39 year-old schizophrenic with poly-substance abuse.
  6. 98 year old female, nursing home patient, with multi-infarct dementia, bed-bound, with advanced contractures.
  7. 56 year-old male with hypertension and Stage IV prostate cancer.
  8.  45 year-old female with hypertension, and advanced renal insufficiency, referred for dialysis.
  9. 38 year-old wheelchair dependent male, morbidly obese, BMI > 40, referred for gastric bypass.
  10. 39 year old female with Stage III breast cancer.
  11. 82 year old male with hypertension, otherwise healthy, needing primary care.

These are all patients that I have seen and so have you.  They all genuinely need care, entail different levels of expense, and have different prognoses.  Under single-payer, the taxpayers through their representatives have to make relative value judgments regarding each case, each life.  This is not some half-baked med school ethics problem, as we cannot afford to give complete care for each of them.  We can give substandard care to several of them, or simply deny coverage to one of them.  That is what single-payer means, worse still than the shambles that is the current government-skewed mess.  Who should we pick?

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  3 comments for “Tough Choices by Pat Conrad MD

  1. politovski
    May 15, 2017 at 12:21 pm

    perhaps another thought experiment for your consideration: we have x number of citizens, and y amount of resources for health care. therefore, if evenly distributed, everyone gets y/x. however, x is constantly increasing and y is a finite number, and therefore we cannot logically have everyone getting unlimited care. rationing is a necessity, as logically we cannot do otherwise. we ration now, but we have people who have a profit motive making the decisions in how to ration, and please be honest and try not to kid yourselves as to what is really going on. we ration stupidly. we pay insurance to pay middlemen to live lavishly, and offer unlimited care to end stage disease. for those of us that believe in a fiscally conservative approach, choices will need to be made. i think that end stage diseases should get hospice, no maximal care, as it does no good and only harms the patient and spends resources needlessly. i agree with the premise of eliminating insurances from the game. i would also like to see prices standardized as they are in japan. perhaps then we will see some change.

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  2. Fred Powell
    May 15, 2017 at 7:54 am

    Good article. I have found myself lately thinking that single payer would be better than having all these rat bastard insurance companies. I cannot even get medicare rates out of them. At least then I’d be getting medicare rates to see patients, and I have to admit, I will not feel sorry for the insurance companies that have taken advantage of us all for years.

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  3. Thomas Guastavino
    May 15, 2017 at 7:12 am

    Whenever there is chaos it is usually the complacent that takes the biggest hit. Whatever “health care system” emerges we have to make sure it is not us who take that hit and that means union.

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