Medicare for All means rationing
Institute for Policy Innovation, March 27, 2019, https://www.ipi.org/ipi_issues/article_detail.asp?name=what-medicare-for-all-supporters-wont-tell-you, What Medicare-for-All Supporters Won’t Tell You
All government-run health care programs ration care. Some rationing is subtle, some is blatant. But they all do it. When the government pays for health care, it must compete against other claims on government funding, such as welfare, defense and education. As a result, there is never enough money to go around. NEVER! So politicians look for subtle ways to limit health care spending that affect smaller populations to free up money for other claims on government funds. That means cutting at the margins, at least initially: the very old, the very young, and the very sick—i.e., people who typically don’t vote. Thus a 65-year old might be able to receive a pacemaker but perhaps not at 75 or 85. An otherwise healthy teenager hurt in a car accident might receive significant resources, while a premature infant with only a small chance to survive might not. It may sound cruel but it makes sense. Given a zero-sum game, where a dollar spent on one patient is a dollar that can’t be spent on another, maximizing the benefit is likely the best way to decide who receives how much. Another way to ration is through waiting. For years the Vancouver-based Fraser Institute has published an annual list of waiting times in Canada. Ironically, among single-payer systems waiting lines can be a feature, not a bug. When famed Canadian pediatric orthopedic surgeon Dr. Walter Bobechko invented a spinal clamp for children with scoliosis—known as the Bobechko clamp—that would help them leave the hospital in a few days rather than several weeks, he claimed hospital management criticized him.5 Those quicker departures opened up beds sooner, creating additional costs for the hospital’s limited budget. Dr. Bobechko eventually left Canada to practice medicine in Texas. The U.S., by contrast, generally has an open-ended health care spending system, even for the two largest government-run programs, Medicare and Medicaid. However, because both programs impose price controls, patients may be denied certain therapeutic options—e.g., more expensive medical devices or pharmaceuticals—and doctors’ offices may limit their Medicare and Medicaid patient loads, creating longer waits to see a doctor. While there is already rationing for both Medicare and Medicaid patients, it is often limited and subtle. Under M4A rationing will be open and explicit—and widespread.
Rationing denies care to the disabled
Patricia Williams, law professor, Northwestern, August 2020, Williams, Patricia J., The Endless Looping of Public Health and Scientific Racism (July 31, 2020). Burris, S., de Guia, S., Gable, L., Levin, D.E., Parmet, W.E., Terry, N.P. (Eds.) (2020). Assessing Legal Responses to COVID-19. Boston: Public Health Law Watch., Available at SSRN: https://ssrn.com/abstract=3681399
Rationing Care During the Pandemic Again, I raise these stereotypes in order to ponder the medical consequence of such epistemic foolishness at a moment when COVID-19’s disparate toll on black and brown bodies has directed much attention to “underlying conditions.” Careful commentators will point out that underlying conditions are not the same as innate predisposition: there is no known human immunity to this coronavirus. And while age and illness may diminish our immune system’s response to any pathogen, that greater susceptibility is merely a probability indicative of neither any human predisposition nor any natural immunity. Our universal susceptibility to it is underscored precisely by the virus’ being “novel.” It bears repeating that underlying conditions like rates of stress, diabetes, asthma, and crowded living conditions and overrepresentation in risky jobs are factors directly accounting for greater intensity of affliction. We know this—this is not a mystery. Given this, attention to the fate of people of color is both overdue and double-edged: it highlights inequities but also risks reinforcing hem as innate. For example, if the United States’ rates of infection are wildly off the charts compared to other nations, we do not generally blame it on the innate conditions of a peculiarly “American” biology; we know these numbers are the product of poor policy decisions. Just so, disproportionate deaths among communities of color must not be attributed to an imagined separateness of “African American” biology. Yet, that is precisely the risk! Amid a welter of misguided fantasies of “sub-species,” “bad blood,” and dissolute traits, we forget at our peril that the trauma and social factors disproportionately affecting people of color are also driving death rates among whites—if not to the same degree. Trap white people in crowded, poisoned, impoverished contexts and they die too. The proposal to use race or ethnicity as a marker of disease vulnerability performs its persuasive labor by appealing to life-saving potential where confined to the context of vaccine prioritization. But it remains to be seen how race will intersect with the usages of vulnerability for purposes of triage in hospital settings. COVID-19 reduces us all to frail, wheezing, non-essential, bare bodies. When we arrive at the emergency room, we are delivered as mere bags of bones among so many “burdening” the health care system. Anonymously quarantined in isolated wards, not visibly marked as a uniquely beloved soul with dear family and networks of friends—is bad enough without having race deployed as an additional cipher for poor outcome. With a shortage of ICU beds, such a cipher will likely be algorithmically weighted as well, for algorithms are more efficient than the Horae, and doctors are really quite busy these days. Recognizing the risks of bias in such emergency circumstances, the Department of Health and Human Services’ Office of Civil Rights issued a bulletin on March 28, 2020, restating a federal commitment to protecting “the equal dignity of every human life from ruthless utilitarianism.” Under both the Americans with Disabilities Act and the Affordable Care Act, people “should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative ‘worth’ based on the presence or absence of disabilities or age.” The underlying concern is exemplified by the case of Michael Hickson, a black quadriplegic whose COVID-19 care was withdrawn by St. David’s South Austin Medical Center after a doctor told his wife: “…his quality of life—he doesn’t have much of one.” His wife was recorded asking pointedly: “Because he’s paralyzed with a brain injury, he doesn’t have quality of life?” The doctor answered in the affirmative (Shapiro, 2020). The New England Journal of Medicine has run a number of articles about triage in the face of shortages of ventilators. Here is one such take: Triage proceeds in three steps: 1. application of exclusion criteria, such as irreversible shock; 2. assessment of mortality risk using the Sequential Organ Failure Assessment (SOFA) score, to determine priority for initiating ventilation; and 3. repeat assessments over time, such that patients whose condition is not improving are removed from the ventilator to make it available for another patient. (Shapiro, 2020). Number one covers the direst instances—crudely put, those who do not stand a chance. Number two, mortality risk, may encompass a lot of us who are older or who have disabilities or other pre-existing conditions. And since there is overlap between long-term stress, environmental poisoning, poverty, lack of medical insurance and such conditions, there is quite a perfect storm of collective mortality risk clustered by zip code and histories of real estate segregation. Number three, “repeat assessment” of whether to free life support for another patient is interpellated by availability of resources that will be in shorter and shorter supply as the numbers of sick and dying continue to climb. Ideally, such assessment is supposed to be done by committee, in conversation with family members or surrogates, and done with consideration of a patient’s Do Not Resuscitate orders. But, in a pandemic or other emergency, decisions to withdraw care are frequently up to a single doctor or resident or perhaps a nurse. In other words, given the mounting numbers, it will probably be up to a highly stressed, overworked, frightened, sleep-deprived human being who has no relation to you but the abstractions of your temperature, oxygenation rate, age, and whatever else that singular individual medical professional finds to read onto, into, or out one’s body.Discrimination against those with loosely defined disabilitiesis already quite common; the University of Washington MedicalCenter, for example, has argued for “weighing the survival ofyoung, otherwise-healthy patients more heavily than that ofolder, chronically debilitated patients” (Ne’eman, 2020). The reconfigured overlay of race as itself a debilitating, resourceconsuming morbidity-risk worsens the situation. Disability rights advocates have worked hard to push these concerns to the front burner, urging Congress to ban triage based on “anticipated or demonstrated resource-intensity needs, the relative survival probabilities of patients deemed likely to benefit from medical treatment, and assessments of pre- or post-treatment quality of life” (Solomon et al., 2020; see also Chapter 34). On July 22, the advocacy organization Disability Rights Texas filed a complaint withHHS against the North Central Texas Trauma Regional Advisory Council for its use of a rigid, point-based, algorithmic scoring system, which can automatically exclude from intensive care persons with a range of pre-existing conditions and disabilities without resort to individual assessment. Other states are beginning to reexamine their crisis rules in response to such concerns. Political Consequences of Treating Race as Biological Destiny Perceptions of disease, deviance, and disgust have always enabled time-worn and hypnotic constructions of embodied difference to be carried forward. When The New Yorker Magazine chose “The Black Plague” as a title for a really excellent piece about COVID-19 by the very insightful author Keeanga-Yahmahtta Taylor, there was a some pushback and rethinking of that as an unfortunate choice allowing some to think of the disease as not really affecting young white people partying on Florida beaches. More obviously and more powerfully, when Donald Trump speaks of “the China virus,” he not only gives the disease a race and a place; true to his outsized colonial imagination, he gives it distance. It’s “over there,” not here, well removed from the conceptual possibility of “our” susceptibility. If “we” are afflicted, it is not just the illness thatdebilitates us but anger that we have been invaded by “them.” It is this form of displaced animus that one saw in the spikes of antiAsian prejudice that arose in the wake of outbreaks of smallpox in San Francisco’s Chinatown in the 1800’s and that culminated in the Chinese Exclusion Act of 1882. Anti-Semitic nativism targeted Jews after bouts of typhus in 1892 (Wald, 2008). Mary Mallon, or “Typhoid Mary,” was an asymptomatic carrier of typhoid fever; her arrest in 1907 on public health charges galvanized much anti-Irish sentiment in New York City, figuring them as immigrants importing unsanitary and slovenly habits (Wald, 2008; Schweik, 2009). When the AIDS epidemic first started spreading in the 1980’s, some people told themselves it was a disease conveniently localized to the bodies of “gay men.” And when Zika virus was carried from equatorial regions by mosquitos riding the waves of climate change, New York City health officials sprayed insecticide by zip code (focusing on East Flatbush, Bed-Stuy, Crown Heights and Brownsville in Brooklyn, and in upper Manhattan, in the neighborhood once known as “Spanish Harlem”) (Frishberg, 2016), as though those pesky identitypoliticking mosquitos could simply be red-lined (Denis, 2020). Instead of coming together around our shared vulnerability, time and again we have created a set of golems to stand in for a pathogen, divisive demons that direct our fears of inherent virulence, murderous voraciousness and leech-like parasitism. Asians. “