Tuesday, November 03, 2009

State of Health - 2

Returning to Southern Cross, the pressures of increasing demand for new treatments and higher technology solutions are having impact. It is leading to the prospect of large increases in premiums. In many cases the premiums are already too high to be affordable - note SC's own comments on people not renewing, or down-grading, current cover.

Further, these impacts are being felt in the public health system as well. The herceptin debacle was eventually funded (in the first year) out of Auntie Helen's Charity Fund (otherwise known as "The Prime Minister's Discretionary Fund") but I do not doubt that it is now an established part of Vote Health.

If we look behind the political rhetoric and wailing and gnashing of teeth there is a very fundamental problem with the provision of health services. Essentially, no one wants to die. I can't blame people for feeling that way. After all, we have the ability today to ensure the survival of some 1% of all live births who when I was born would have been "sad but inevitable consequences" of premature birth. I would be one of the last to try and suggest that we should turn our backs on that ability. We have the ability to turn around the lives and health of reprobates like the ol' probligo with what is now a relatively routine opration, complex but routine. On pure observation, there must be some 1,000 people a year whose lives are improved immeasurably if not saved as a result. Those having pacemakers fitted come into a further 1000 a year. That is just one hospital.

The problem of the cost is one that has actually been with us for a lot longer than we might want to admit. It is not limited to NZ either.

If I return to the commenter whose thoughts started all of this off, I wish him and TF and everyone fighting the good cause against Obama the very best of luck. Why? Because the choice is very simple.

Generally, private insurance and health providers are by their very nature required to make a return on their investment if not an additional return for those whose money made the investments in the first place. The argument in favour of public provision is based (in theory) on universal cover and no profit.

Irrespective of how you add those two quite different proposals there are common impacts upon how much has to be paid for them. I have covered those already.

The truth is that there is a limit between cost, availability, technology and outcome; a "mathematical" limit as well as economic and "social".

The ultimate and universal outcome for all is death. The "social" end of the limit wants that outcome minimised as far as possible and delayed for as long as possible given that it is a certainty for all (at least at present). There is much that can be argued about the causes and nature of a person's death. I do not think that this is the place for that debate other than to suggest that its inevitability has to be recognised.

The ultimate technology would have to be (effectively) eternal life. There was comment made last night on tv that in the Middle Ages the average life span was 30 years. A man of 40 would be considered elderly. A man of 60 years almost unheard of. Needless to say, aging diseases such as cancer, alzheimers, coronary heart disease were unheard of and unrecognised. In the 1800's in Europe and America, the average lifespan might have increased to 55. In the past 15 years the average lifespan for men in NZ has increased from 71 to 82; the life expectancy of a newborn is something like 62, but once past the age of 15 it increases to 85. It is expected that the number of people reaching 100 years in 60 years time will be double that of the present day. In very large part that increase in life expectancy is the result of improving technology.

The ultimate in availability is universal. It is here that most of the heat and darkness arises. "Why should I pay..." is fundamental to both sides; with the sentence ending "...for anyone else" on one side and "...more than the true cost" on the other leading to "...more than I can afford" again on the other side of the lake. What must be decided by society, not by the medical profession or the government, is who should be able to access medical services. The "rich" will always be able to afford to buy; "rich" because that is a matter of perspective as much as it is of fact (compared to half of NZ I am a "rich" man yet as I said at the beginning paying for personal medical insurance is almost out of reach).

The decision on public health services needs to come back to the fundamentals I began with - curing diseases, mending injuries, and providing palliative care for the dying.

The debate must centre on the immediate cost of treatment against the benefit to society of the likely outcome. Is that a simple judgement? Not in my book! What is certain is that it is a necessary debate. Nor can the availability of health services be limited to those with the ability to pay. There has to be a universality in health services. The scope of that universality has to be unlimited. That means that the universal care will necessarily provide services which are below the available technology and ability.

Not an attractive thought.

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