Topic: Health Care & Welfare

Conscientious Objectors

Can pharmacists have a conscience? Activists are demanding that Congress and state legislatures pass laws forcing pharmacists and other health workers to act against their own conscience in such matters as abortion, morning-after pills, and gay parenting.

Some doctors say it violates their conscience to perform abortions or provide artificial insemination for unmarried or gay people. Some pharmacists believe that the morning-after pill is a form of abortion, and their religious commitment forbids them to dispense it.

And now some patients and activists are demanding laws to force health professionals to dispense the care the patients want, no matter how it violates the health worker’s conscience. Activists who march for a woman’s right to choose want the government to overrule a pharmacist’s right to choose.

I was reminded of Arnold Kling’s question “Is Bioethics an Oxymoron?” when I read in the Washington Post the comments of official bioethicist R. Alta Charo: “As soon as you become a licensed professional, you take on certain obligations to act like a professional, which means your patients come first.” As I wrote in an online debate for Legal Affairs magazine,

this is an example of how one state intervention generates the demand for additional interventions. We say you can’t be a pharmacist unless you get a state license, and now you want to say that that license should empower the state to impose morally offensive obligations on those who were required to get the license.

Similarly, we require a prescription to get many drugs, including some forms of contraception. Why should a woman need a prescription for contraception? Why not just grant access to contraception by allowing it to be sold over the counter? Here we’ve created one intervention—the requirement that people get a prescription from a licensed doctor, which they must take to a licensed pharmacist—and it has led to a situation you don’t like, in which some tiny number of pharmacists are refusing to dispense a particular prescription. So you say we should have another rule, another regulation, another intervention.

As philosopher Loren Lomasky of the University of Virginia puts it in the Post article, “Freedom of conscience has been central to our political notions since even before the United States existed. People should not be forced into doing things that they find morally odious.”

Do the people who want doctors and pharmacists to be forced to provide abortions and morning-after pills want anesthesiologists to be forced to participate in executions? I’d bet not. These activists want their moral values enforced by law, they don’t want a neutral rule that all doctors must obey the laws of the state. If they did take such a consistent position, of course, I’d still disagree: anesthesiologists shouldn’t be forced to participate in what they may regard as murder, any more than gynecologists should.

This seems like such a clear issue to me. Yet most of the people in the Post’s online chat about the issue were insistent that health workers must be forced to do as they’re told, regardless of their own conscience. Whatever happened to the liberal claims of individual autonomy, of the right of conscience, of the individual exercising his or her own mind? Gone with the wind, it seems, when liberals have the power to impose their values on other people’s consciences.

In a country of 290 million people and 14 million businesses, we should let these issues sort themselves out in the marketplace. Chances are that major drugstore chains like CVS and Walgreen’s are going to insist that their stores fill all prescriptions. If they have more than one pharmacist on duty at a time, then they may be willing to tolerate pharmacists who avoid filling certain prescriptions. If they do insist that all pharmacists be prepared to fill any prescription presented by a customer, then pharmacists who can’t accept such rules will have to look for jobs elsewhere. And if customers encounter a pharmacy that won’t give them what they want, then they will have to find another pharmacy.

A prime reason for freedom is pluralism. In the modern world we don’t all share the same moral and religious perspectives. The fact of moral diversity is a good reason for toleration and allowing people to sort themselves out in society according to their own moral choices. Freedom in a pluralistic society should mean that individuals get to make their own choices. Sometimes other people aren’t willing to do what we want them to do. But frankly, it’s involuntary servitude to force other people to work for us when they prefer not to. And it’s appalling that 141 years after the Thirteenth Amendment, some people still want to hold others to involuntary servitude.

No Need for a Mandate

Much of the justification for an individual health insurance mandate, like that pushed by Massachusetts Governor Mitt Romney and the Heritage Foundation, is that people who lack insurance in the current system still receive medical treatment when needed.  The cost of treating these “free riders” is shifted to the insured and the taxpayer.  In particular, it is suggested that these uninsured individuals will end up at hospital emergency rooms.  Advocates of universal single-payer systems often make similar arguments.

But a new study in Health Affairs shows that that there is no significant difference in emergency room use between insured and uninsured populations.  The study concludes that increases in the number of uninsured are not likely to lead to an increase in emergency room visits.  However, the study does show that Medicaid beneficiaries use emergency rooms more than either the insured or the uninsured.  This may result both from the difficulty that Medicaid patients have in finding primary-care physicians willing to treat them at Medicaid’s low reimbursement rates, and from the fact that emergency room visits are essentially free for the Medicaid patient.

One other finding is worth noting as well.  Contrary to public perception, noncitizen immigrants actually use emergency rooms less than citizens.  Emergency rooms are not being overrun by illegal immigrants.

Premium Medicine vs. Watchful Waiting

In a response to my defense of health savings accounts, Dr. Hébert makes a thoughtful case for the value added by primary care physicians. One way that PCPs add value is through “watchful waiting”:

It used to be that observation was one of the mainstays of medicine. Now everything is scanned, biopsied, and aggressively worked up because specialists find it easier to bill for expensive procedures than for recurring office visits. This shift away from observation towards aggression runs the risk of hurting patients, and is one of the casualties of the microspecialist system.

The (over-) use of such “premium medicine” is one of the main themes of Crisis of Abundance, a new book by Cato adjunct scholar Arnold Kling. As an illustration, Kling writes about a blogger named Quixote who received intensive treatment for her swollen eye:

My guess is that 30 years ago, a patient with similar symptoms would have been treated “empirically,” a term doctors use to describe a situation for which they do not have a precise diagnosis and treatment, so that instead they must use guesswork. A layman’s synonym for treated empirically would be “trial and error.” In this case, the patient might have been sent home with an antibiotic and perhaps a prescription for Prednisone, a steroid used to reduce inflammation. There would have been nothing else to do. In 1975, computerized medical imaging technology was new and exotic, with limited applications.

In contrast, in 2005, over the course of a few days Quixote was given a computed tomography (CT) scan, referred to a specialist, sent to a different hospital, referred to a specialty clinic, seen by a battery of specialists there, and given yet another CT scan. Ultimately, however, she was sent home, as she might have been 30 years ago, with an antibiotic, Prednisone, and no firm diagnosis.

Compared with 30 years ago, Quixote received more services, in the form of specialist consultations and high-tech diagnostics. However, the ultimate treatment and outcome were no different. This does not mean that medicine is no better today than it was a generation ago. The CT scans and specialist consultations could have turned out differently. They might have been critically important, depending on her actual condition. Under some circumstances, treating Quixote empirically with an antibiotic and Prednisone could have been a mistake, perhaps costing some or all of her sight in one eye.

Such is modern medicine in the United States. Doctors are able to take extra precautions. They can use more specialized knowledge and better technology to try to pin down the diagnosis. They can perform tests to rule out improbable but dangerous conditions. But only in a minority of cases does the outcome deviate from what would have been the case 30 years ago.

That’s from chapter one. The remaining chapters wrestle with the question of when we should make use of premium medicine.

(The Cato Institute will host a book forum for Crisis of Abundance from 12-2pm at Cato on Tuesday, August 29. Kling will present, and the Washington Post’s Sebastian Mallaby and NYU’s Jason Furman will comment on the book. Keep watching www.cato.org for more details.)

The Glories of a ‘Single Payer’ Health Care System

I recently attended a conference at Cambridge University, mainly involving Brits, none of whom had a good word to say about the National Health Service. What a change from times past, when so many British people thought it a matter of national pride to boast that “We have the finest health care system in the world.” (When I lived in the UK, I used to ask such people to what world they were referring, ‘cause it sure wasn’t this one.)

Lo and behold, the NHS just released data on “hidden waits,” the time spent waiting for diagnostic tests. As the BBC noted in its coverage:

The figures, for 15 of the most common diagnostic tests including scans, internal examinations and hearing tests, mean that for many patients the wait for diagnosis is as long as the wait for treatment.

If you’re going to get sick with anything serious, be sure to do it in the United States. Even with all the problems facing American medicine and the irrationalities of our financing system, at least you’re likely to find out how sick you are and start treatment before it’s too late.

Medicare Reform: Just Give Seniors the Cash

Matthew Holt at TheHealthCareBlog.com raises a good question about Medicare’s renewed effort to offer medical savings accounts to beneficiaries:

Those taxpayers who can do basic math might wonder why you’d want to to give healthy Medicare beneficiaries cash for health services that they’re not going to use, while taking that cash away from the pot that pays for the sick beneficiaries that do use said services. But we’ve asked that question so many times before and no one on the free market side dare answer it. And I guess you might say, why not give the taxpayers money straight to the “healthys” instead of laundering it through Medicare Advantage plans as we’re doing it now so that they can hand out free gym memberships to seniors and boost their executives’ stock holdings.

But given that risk adjustment is coming to Medicare Advantage, it may be that that gravy train is ending.

The Medicare MSA concept raises some interesting problems. Fortunately, Holt solves them — though I’m not sure he knows it.

A bit of background: The Medicare Advantage program currently pays private health insurers a flat amount for each senior those plans cover. As Holt notes, that encourages the plans to seek out the seniors whose medical bills will be less than that flat amount. Thus some plans “hand out free gym memberships to seniors” as a way to attract the healthy, profitable ones and avoid the unprofitable sick ones. That can end up costing taxpayers more than if those healthy seniors just stayed in traditional Medicare. 

But as Holt says, Medicare is working on adjusting those payments according to each beneficiary’s health risk. Instead of some flat amount per beneficiary, insurers would receive a payment from Medicare that better reflects each individual enrollee’s expected medical expenses. That way, health plans would have less reason to cater to the healthy or to avoid the sick. 

But once Medicare risk-adjusts those payments, why should the insurance companies get that money? As Holt postulates and Mike Tanner and I discuss in Healthy Competition, why not give it to the beneficiary? Confine it to health care uses, if you like. Healthy people would get smaller payments; sicker seniors would get larger ones. That would enable each to purchase health coverage (high-deductible or whatever) and still have some money left over for their out-of-pocket expenses. Seniors would get more control over their health care and coverage; they would make much smarter cost-benefit decisions than they do now; and Congress could limit the burden that Medicare imposes on taxpayers.

Is the point of the program to help insurers? Or providers? Or seniors? To whom do we want insurers and providers to be responsive?

The Spin on Medicaid

The Administration claimed this week that Medicare and Medicaid spending has slowed, but a close look at the overall picture tells a different story. My colleague Michael Cannon has already posted his opinion about Medicare spending.  Here’s the low-down on Medicaid.

The official spin:

Medicaid cost projections are once again declining, reflecting … a slowdown in Federal Medicaid spending growth from over 12 percent per year in fiscal year 2000-2002 to 7.2 percent from 2002-2005, down further to 4.6 percent projected for fiscal year 2006-2007.

And the complete story:

Summary budget tables – updated during the release of the Administration’s Mid-Session Review of the Budget this week – indicate that federal Medicaid and SCHIP (State Children’s Health Insurance Program – also a part of Medicaid) outlays would grow from $129 billion in 2001 to $213 billion by 2008.  That’s a cumulative (geometric) annual average growth rate of 7.7 percent during the Administration’s full tenure.  The nation’s Gross Domestic Product, on the other hand, would grow at a much slower pace – just 5.2 percent per year during the same period.

Much of Medicaid spending growth resulted from the substantial surge in enrollments and benefits per enrollee during the aftermath of the 2001 recession.  Medicaid outlays would be expected to surge during recessions but should abate when growth picks up.  The latter did not occur during the 1991 and 2001 recession episodes.  During the later recession, changes in federal regulations made it easier for states to expand coverage to broader groups and claim federal matching grants against such coverage.  And evidence from micro-data surveys indicates that it was not the poorest groups that received most of the latest increases in Medicaid coverage and benefits.

The reasons for the current slower growth in Medicaid spending are the transfer of the fastest growing prescription drug coverage to Medicare and robust economic growth.  However, according to the Administration’s projections, faster Medicaid spending growth – at 7-plus percent per year – is projected to resume after 2007.

Providing greater power to states to redesign their programs while persisting with a federal financing mechanism of matching grants (rather than block grants with capped growth) promotes states’ incentives to spend more. That will cause…you guessed it…more spending on our middle-class Medicaid entitlement.

Bush Administration’s Reputation for Truth-in-Medicare Sinks. Even. Lower.

I just received a blast email from our friends at the federal Centers for Medicare & Medicaid Services. The subject line reads:

Medicare & Medicaid Spending Projections Are Down Again

Medicare spending is down? HUZZAH! A joyous day for taxpayers, one and all. Wait…what’s that you say? Go beyond the press release and read the actual report the administration released? Okay:

At $2.696 trillion, outlays for 2006 are now estimated to be $12 billion lower than the level estimated in February, accounting for 10 percent of the reduction in the 2006 deficit. The lower estimate of 2006 outlays results primarily from reductions in the projected growth rates for Medicare and Medicaid, particularly estimates of the cost of Medicare’s new prescription drug benefit program… However, in the traditional Medicare fee-for-service programs, projections of increased spending outstrip these savings in the long-term and as a result, total spending in the Medicare and Medicaid programs continues to grow at unsustainable rates.

What? Projections of increased spending outstrip these savings in the long-term? Sometimes I get this wierd feeling that the Bush administration is trying to mislead me.

(My colleague Jagadeesh Gokhale will evaluate the Bush administration’s claims about Medicaid spending in a subsequent post.)