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?

99690cookie-checkTough Choices by Pat Conrad MD