How much medical care does society owe Americans that they could not otherwise afford? It’s not a philosophical question, such as how many angels can dance on the head of a pin. This question plays out every day. For instance, I have an Obamacare plan with premiums of more than $7,000 a year with a deductible that’s more than $8,000. Basically, I pay premiums for coverage that affords me very little benefit and the premiums are probably triple what they should be so that a few enrollees can get more medical care than without my subsidy. I probably pay a health care subsidy of $3,000 to $5,000 annually towards other peoples’ health care in addition to the income taxes I pay separately that goes for Medicare, Medicaid charity care.
The fastest growing area of drug expenditures are for specialty drugs. Specialty drug is the name given to any drug that costs more than $18,000 a year, but some drugs costs far more. The most expensive drug is a hemophilia drug that costs $3.5 million for a one-time dose. The top five most expensive drugs cost more than $2 million for a one-time dose. There are four more drugs that cost just over $1 million annually. Indeed, about half of all prescription drug spending is on hyper-expensive medications that few people need.
Before Obamacare health plans could stop paying after, say, $500,000 in a given year or lifetime spending of $1 million or more. The Affordable Care Act put a stop to annual caps and lifetime caps on benefits. That is essentially why we now have drugs that cost $1 million a year or $3.5 million for a single dose. The fact that insured patients do not face a hard budget constraint when it comes to expensive medical procedures is partly what is driving excessive medical spending. It’s not just the fact that patients are able to consume medical care they otherwise could not afford. It’s also that they are not price sensitive, demanding expensive care that offers very few benefits because they bear little of the cost. Price sensitivity is especially low in life and death matters.
Life-support machines can keep patients alive in a vegetative state. In some cases these machines keep patients technically alive for months or even years. The Wall Street Journal wrote about ECMO machines, that oxygenates blood and removes carbon dioxide, performing the work of lungs.
After Covid-19 ravaged the 51-year-old’s lungs in July 2021, doctors at a hospital in Phoenix used a machine known as an ECMO to keep him alive. His condition got worse. The next month, a doctor brought up how badly he was doing to prepare his wife for the possibility that continuing ECMO treatment might become futile.
The machines are often used as a bridge when heart-lung transplant patients need time to recover. There are times, however, when patients are unlikely to recover yet the machines keep them alive. That raises an ethical question: how much is too much and when it is time to let go. More from WSJ:
The machines are meant as a bridge out of crisis, to recovery or a transplant. But some patients have lived on them for more than 600 days. And some patients deteriorate past a point where they could live without the machines. Doctors then have to make ethically and emotionally difficult decisions on when to withdraw ECMO support. In some cases, they work with family members and patients to select a date.
Some patients on ECMO machines are alert, conscious and may even be able to converse with family members. Does that mean hospitals have a duty to house patients for years on ECMO machines? What about skilled nursing facilities: should nursing homes be required to buy these machines and keep people alive tethered to a machine? If so, who is going to pay?
“What is so different with ECMO is that you can be living in a way you might find acceptable. And we say it has to end,” said Dr. Daniela Lamas, a pulmonary and critical-care specialist at Brigham and Women’s Hospital in Boston. “That is wild. Who decides what kind of life has quality?”
About 90% of people have health status that is good, very good or excellent. The remainder have health status that is fair (8%) or poor (2%). Data shows that 20% of the population accounts for 80% of health expenditures, while 5% of the population accounts for about half of medical spending in any given year. By its very nature, the vast majority of health insurance premiums (and Medicare spending) is on a small segment of the population.
The United States spends nearly 20% of gross domestic product (GDP) on health care. Should we spend more? We could spend our entire GPD on health care in useful ways but that would leave nothing for housing, transportation, entertainment, food or clothing. In the coming years should Americans adapt to dorm-style housing, with communal bathrooms; and trade private car ownership for public transportation so that more of our GDP can go for extreme medical care? It’s an important question. At some point Americans will have to decide how much of their standard of living they are willing to sacrifice for more expensive medical care, much of which won’t benefit them.