By Wesley J. Smith
Health-care costs are soaring, in part because the medical field is increasingly being put into harness to facilitate lifestyle and self-fulfillment desires. So the pressure is on to ration health care. If we are not careful, rationing could be wielded in an invidious manner against the very sick, elderly, disabled, and those seen as nonproductive.
A prime rationing approach in this regard is known as the “quality-adjusted life year” (QALY) scheme. It works, very roughly, like this: Let’s say John is hit in the prime of life with a serious illness and that medicine A would likely give him two more years with a good quality of life as an able-bodied man. The cost would be $100,000. That would be worth, roughly two QALYs (less if he is elderly, but let’s not get too complicated here).
Now assume that his paralyzed twin brother Mark contracts the same illness. Just as with John, medicine A would give Mark two years of life at his current level as a man with a serious disability. Because Mark is paralyzed, the rationing bureaucrats might deem his two years of actual life worth only 0.5 QALY.
Then, the cost/benefit is measured, determining whether the cost of medicine A is worth the number of QALYs it would provide. Under this approach, John would be more likely than Mark to receive the treatment because the $100,000 would give him two QALYs, versus Mark’s 0.5 QALY — even though their actual lives would be extended an equal amount of real time for an identical price.
The above (simplified) description illustrates the potential for discrimination under a QALY system — which is why the disability-rights community adamantly opposes the QALY scheme and wants Congress to outlaw it in federal programs. This isn’t paranoia. As a detailed report published by the National Council on Disabilities published in 2019 noted, patients with disabilities in countries that have adopted the QALY rationing system have witnessed “coverage denials and loss of access to care.”
QALY rationing was banned under the Affordable Care Act; the ban was necessary to get it passed but opposed (naturally) by the New England Journal of Medicine. Now, the Protecting Health Care for All Patients Act (H.R. 485) has been put in the hopper to prohibit “the use of quality-adjusted life years and similar measures in coverage and payment determinations under Federal health care programs.”
Once again, the medical and bioethics establishments are opposed. In “Congress’ Misguided Plan to Ban QALYs,” a recent opinion piece in the Journal of the American Medical Association, the bioethicist co-authors worry that banning QALYs will harm the ability of the government to negotiate drug prices. But I think their real concern is this:
The idea that negotiating prices using QALYs will restrict access to care relies on the unrealistic premise that people can afford all health care services, no matter the cost. In the US, high costs routinely inhibit patient access to necessary health care services. One in 4 people in the United States do not take their medications as prescribed because of the cost. Annual insurance premiums for a family now exceed the cost of a new car.
If members of Congress are truly concerned about access to health care, they should encourage government and private payers to use all the tools they can to negotiate fair and affordable prices for the health services they cover.
Well, then stop expanding the elective procedures that have to be covered because it makes people “feel” more fulfilled. Allow more free-market remedies to harness the power of competition to reduce prices. Increase the scope of Health Savings Accounts.
But formal rationing? Not on a bet. Why? Because rationing is inherently political, meaning that decisions about who will be denied access to efficacious treatment will depend on who wields political power in society.
In the current environment, that means expensive surgeries and other medical interventions deemed to further woke goals of equity and social justice will never be curtailed. But I would oppose rationing if the country’s power was held by social conservatives. Rationing leads to the powerless being denied access to care that the well-connected can attain.
Unless QALY rationing is prohibited, people with disabilities, the frail elderly, and chronically and terminally ill people could well see their medical options curtailed based on what bean counters, “experts,” and public-opinion surveys think about the quality of their lives. That’s unacceptable. Pass H.R. 485.
Editor’s note. Wesley’s great columns appear at National Review Online and are reposted with his permission.