washingtonpost.com
Opinion focus with Eugene Robinson: Why we can't stomach health-care rationing

Eugene Robinson
Washington Post Columnist
Tuesday, November 24, 2009 1:00 PM

Washington Post columnist Eugene Robinson was online Tuesday, Nov. 24 to discuss his recent columns and the latest news.

The transcript follows.

Archive of past discussions.

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Eugene Robinson: Hi, everyone. No preliminaries today. I wrote about health care this morning, but as usual everything's on the table. Looks like the Afghanistan decision is coming soon. Let's begin.

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Kingsland, Ga.: I don't disagree at all with your assessment: health care is going to be rationed, one way or another, whether it's by ability to pay, or by some other, more arbitrary, rules. And it's the "arbitrary" which makes people draw lines in the sand.

Do you have any ideas of how this economic reality could be presented and implemented? It seems that politicians never really achieve anything meaningful unless they truly fear for their jobs; perhaps the solution to the problem is to somehow leverage that fact. Please let us hear your thoughts.

Eugene Robinson: Politicians' ability to keep their jobs is always an issue. That figures into their calculations about which way to vote on the health care legislation now under consideration. Sen. Blanche Lincoln, for example, has to weigh a possible primary challenge if she votes no on the final bill against possible trouble in the general election if she votes yes. (Although I've seen polls showing that most people in Arkansas want reform to pass -- with a public option.)

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Augusta, Mo: Your view of the need for rationing care is accurate and rarely stated in public. Brownlee's recent book "Overtreated" outlines the central problem with American health care - it's not the uninsured, it's the cost, which is in large part driven by overtreatment. There is no one, alas, with the leadership and political courage who is willing to try to educate Americans why less care is better - less harmful and less costly.

Eugene Robinson: The thing is, we already do ration care. It's just that we do it by income -- who can afford health insurance -- or we let the insurance companies do it for us case by case. But that reality doesn't seem to sink in, even though practically everyone who has insurance has had the experience of having a claim denied.

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Minneapolis: Just don't touch mine. You hit the nail on the head right there. Aside from the socialism canard, opponents are really just worried that health care reform will either lead to restrictions on their current plans or make them more expensive.

There's no sense of community in this discussion. Just don't touch mine.

What it comes down to is blaming the uncovered for their situation. I have mine, why don't you have yours?

Eugene Robinson: Yes. And it's hard to get people to "give up" anything, even if it's not doing them any good. You can look at the statistics proving that many countries with single-payer systems that more overtly ration care have better health outcomes than we do. In life expectancy, we're not number one, or even number two, we're number twenty-seven. But that's looking at it from a aggregate point of view, which I guess is supposed to be socialist thinking -- rather than, "I got mine, who cares about yours?"

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Anonymous: Hi Gene - I'd note that we not only ration out those who cannot afford health care. To use the mammogram example, if insurance pays for tests starting at 40, we ration out younger women, even though some life- threatening cancer that could be treated if discovered early occurs in younger women. Any insurance program must ration or there will be no logical limit on paying costs. At the extreme, are we prepared to pay for unproven therapies that quacks have pushed as life saving? Once we admit that all systems ration, then we can begin to face the appropriate question: what rationing makes sense (e.g., 40 or 50 for mammograms and each year, or every other year). But we also have to face anther reality: there is no amount of health care that will keep each of us from dying. To pay any costs at all, no matter how high, to avoid death, is to deny the reality that we all die.

Eugene Robinson: What? You mean we won't live forever? Let's find a way to blame that on President Obama.

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Surprise, Ariz.: Mr. Robinson, thank you for your thoughtful take on this important subject. Do you think an opportunity exists to create a public/private hybrid, where a basic level of coverage while applying comparative-effectiveness research to control costs is available to everyone, and private insurers could sell supplemental coverages that would be in line with individuals' demand for services and ability to pay?

Eugene Robinson: I don't think the political opportunity for such a robust public role exists right now. As my friend and former colleague T.R. Reid points out in his book "The Healing of America," it is possible to have an excellent single-payer system that's run through private -- though non-profit -- insurance companies, as in a number of industrialized countries. But you can't say "single-payer" or you're a socialist. Another good friend of mine who's an expert on health care says you can have an "all-payer" system that starts (if I understand correctly) by controlling costs at the delivery end but preserves the private insurance market.

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Time for a topic change: I wonder where Al Gore is hiding out, following the discovery of e-mails out of the CRU (Climate Research Unit) of the University of East Anglia that show conspiracy and manipulation of climate data that does not support the Global Warming and greenhouse theory.

Would you support the WaPo making critical investigations into these communications to get to the bottom? Because at first glance, the documents that were released last week really brings into doubt the whole man-made global warming theory.

Eugene Robinson: Quick topic switch: I may do my Friday column on these e-mails. I don't think it throws the whole theory into doubt, but it does raise some questions that ought to be answered.

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New York : Happy Turkey Day, Gene. It's now been disclosed, to nobody's surprise, that Rev. Moon's church has been spending in the tens of millions of dollars yearly to prop up the reactionary Washington Times. -by the way, how do you leave a job there and take a job somewhere else; isn't it a comedown when you've been working for The Messiah?] And the story about liberal hawk Peter Galbreath, who has secretly been on a oil company payroll while drafting the Iraq constitution and writing all those op eds and opinion pieces, is also fresh in our minds, as is the on-going scandal of the cable 'news' shows using paid military flacks to give 'expert' opinions on foreign policy. My question is, should our first impulse be to automatically distrust pundits and talking heads, and assume that many of them are spouting opinions that are bought and paid for by monied interests? Is all of our political discourse approaching the reliability level of info-mercials? Or, from your experience, do you think there is less corruption than would appear to be the case from the headlines?

Eugene Robinson: It's always a good idea to distrust pundits and talking heads, on general principle. Seriously, you have the right to expect full disclosure is the person doing the opining is essentially functioning as a lobbyist. And if there's no disclosure, you have the right to expect that there's no conflict of interest. News organizations try to enforce these standards and usually succeed, but not always.

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Rationing care . . . : You need to ration care, if rationing includes applying medical necessity criteria to requests that don't make medical sense. "Ah, but who are the insurance companies to tell ME that I need to try losing some weight before having surgery." I get the feeling that most people don't understand that medical necessity criteria are developed by a consensus of doctors, not a panel of executives.

And this business of politicizing the new breast cancer screening recommendations are absurd. I guess there is nothing that politicians won't glom onto in the hopes of riling up voters who don't know any better.

The previous poster was exactly right - costs are rising because we insist on having every procedure out there performed, regardless of cost or need. If you don't attempt to control utilization or unit price, all of this legislation is just so much empty air. Thank you, Medicaid & Medicare.

Eugene Robinson: True, but it really is hard to get around the fact that health care is such a personal issue. Take the mammogram recommendations. Yes, it's abhorrent to politicize what should be a matter of science. But anyone who knows a woman whose breast cancer was discovered in her 40s, through a mammogram, and was successfully treated, is going to be hard to convince that the downside of early mammography is greater than the upside.

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60 minutes: Did you see the piece on 60 minutes about rationing healthcare? Specifically, it addressed the exorbitant often wasted cost of end-of-life care. I said to my husband when it aired, we finally found an issue as politically explosive, misunderstood and polarizing as abortion. Frankly, I don't know how the problem can be addressed - I'm not sure it ever will be addressed.

washingtonpost.com: The Cost of Dying (60 Minutes, Nov. 22)

Eugene Robinson: I'm not sure it will, either. Anyone who has had the experience of losing a parent knows that end-of-life decisions are hard and that sound policy is no match for love if the two seem to be in conflict.

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Washington, DC: Traditionally, I thought it was the Democrats who were more irresponsible on health care and Medicare in particular. However, this year the Republicans seem to want to outdo them. The pundit contest winner Kevin Huffman did a good piece on the recent Republican rhetoric. The party of small government now opposes ANY cost control measures. This is clearly an attempt to win votes, but where are conservative non-politician intellectual bigwigs, why aren't they calling their party on this bs. David Frum seemed to a few weeks ago but the rest seem to going along. What is "conservative" about opposing any attempt to control a runaway entitlement program like Medicare?

washingtonpost.com: The Palin take on health-care costs (Post, Nov. 22)

Eugene Robinson: What's conservative about the Republican stance? Not much, in my view. I try to remind readers and viewers that while we obsess over how Ben Nelson, Blanche Lincoln or Mary Landrieu is going to vote on this or that provision, meanwhile there are forty Republican senators who are voting no on everything.

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Richmond, Va.: Do you now consider the claims that we can expand coverage and contain costs with the current bills under consideration in the House and Senate to be dishonest?

My own view is that the Democratic leadership considers the expanded coverage to be the top priority, while the majority of the American people consider controlling the rise in health insurance costs to be more important. If these goals conflict (as alluded to in your column), Democrats may not like the political results of their legislative "victory".

Eugene Robinson: I think the bills being considered do "bend the curve" on costs to some degree, but not nearly as much as is needed. They should leave us better than the status quo. And I only wish that expanded coverage was the Democratic majority's overarching priority. I believe it's scandalous and immoral that we've never had truly universal health care in a country that calls itself a beacon to the world. Shame on us.

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Boston: I have a simple question: How did Herbert Hoover end up winning the economic debate with the modern punditry? (And, sadly it now appears he's won the WH too)

Eugene Robinson: Gee, Hoover hasn't won with me. I seem to recall how well his economic ideas worked out.

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clouding the issue?: The whole mammogram debate - true, some, by that I mean a very few, women younger than 40 develop breast cancer. These are usually aggressive and dangerous. Women in a risk category - family history, for example, should get those screenings. Me, an over-fifty woman who has had unremarkable mammograms for several years, was more than pleased when told by my doctor that since there was no history in my family, AND I had clear screens, that I could start doing them every 2 years instead of every year. Instead of talking about rationing or arbitrary age limits, why not apply mitigating factors to whether or not a test is indicated?

Eugene Robinson: That's what the panel recommended, as I understand -- taking risk factors into account.

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To: Rationing Care... and 60 Minutes: The question is, do we want to be the country that tells people they can't have access to the best health care because it costs too much? On an individual basis, it is akin to deciding who gets to enter the bunker before the nuclear fallout. At what point do you tell someone (and yes, it is personal because that is ultimately the scenario), we've decided your time to die is now because you cost too much?

Eugene Robinson: As I recall, on that 60 Minutes report a doctor asked a desperately ill, elderly man -- who was about to undergo an operation -- if he wanted to be resuscitated if he lost cardio-pulmonary function while on the table. He said, essentially, yes indeedy. I don't think we're going to have a system in which somebody tells him no.

But people do manage to die. Doctors make tough decisions every day. I don't envy them.

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Charlotte, NC: Yeah, we all want our treatment to be effective and everybody else's to be efficient. But isn't end-of-life care where we really need to work on controlling costs? Hospice care beats the heck out of dying in a hospital on more levels than efficiency/effectiveness.

We have to do something. In 2005, one of my husband's cousins died of a kidney infection at age 51 because she didn't have insurance and didn't go to the doctor before the disease overwhelmed her body. To deny/delay treatment on the basis of income, which was her issue, is morally wrong, in my opinion. Basic health care should be a public good, just like law enforcement and fire protection, and equally accessible.

Eugene Robinson: I agree. And I'll bet that more money was spent -- sadly, in vain -- trying to treat your husband's cousin's advanced infection than would have been spent to treat it, perhaps successfully, at an earlier stage. Tragic and wrong.

My time is up for today, everybody. Thanks so much for stopping by, and I'll see you again next week. Happy Thanksgiving, all!

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