Congress' implicit healthcare rationing

As an emergency physician and former governor, I am struck by the towering contradictions - and indeed the hypocrisy - in the controversy over the tragic plight of Terri Schiavo. On the same day that the US House of Representatives voted to involve the federal courts in her case, it also approved a 10-year $92-billion cut in Medicaid funding - $30 billion deeper than the cut recommended by President Bush.

The relationship between these two decisions - virtually unreported by most media - goes to the very heart of why we're unable to resolve the growing crisis in our healthcare system. While involving the federal courts in an attempt to save the life of one highly visible individual, Congress made a fiscal decision that will deny thousands of other Americans timely access to healthcare, some of whom may die as a result.

To understand this point is to understand the insidious form of implicit rationing practiced by legislative bodies throughout the nation - starting with the Congress. When the Congress cuts Medicaid funding, it is a direct cost shift to the states that administer the program. However, unlike Congress - which has run up a $7 trillion national debt over the past four years - states are required to operate within a balanced budget. So they respond to cuts in Medicaid by dropping people and/or services from coverage.

In 2003, for example, in an effort to balance the budget in the face of falling revenue due to the recession, the Oregon legislature discontinued prescription-drug coverage for certain categories of citizens covered by the state's Medicaid program. This action was apparently based on the assumption - widespread in legislative circles - that if we just stop paying for the healthcare needs of the poor, they'll somehow go away and the public sector can avoid the cost.

As a consequence of this decision, Douglas Schmidt, a man in his mid-30s suffering from a seizure disorder, was no longer able to afford to purchase the medication that controlled his seizures. He subsequently had a grand mal seizure and suffered severe brain damage. He was put on a ventilator in a Portland hospital, where he remained for several months. Eventually he was transferred to a long-term care facility where he died after life support was withdrawn - following a court order to do so.

The cost of his antiseizure medication was $14 a day; the cost of his hospital care was over $7,500 a day - a total medical bill exceeding $1 million. The legislature saved no money through its implicit rationing decision, yet Mr. Schmidt died of political and budgetary expediency based on a policy that said, in effect, we will not pay pennies for medication to manage a seizure disorder, but will pay thousands of dollars to keep an individual on life support after that unmanaged seizure disorder causes severe brain damage.

It is a policy that says we will not pay to manage many very manageable health issues in ways that would prevent people from ending up in long-term hospital stays; or says we will not pay to provide all pregnant women with good prenatal care, but we will pay to resuscitate their one-pound infants in a neonatal intensive care unit. And this should not be acceptable to any of us.

Certainly no one in Congress could openly support this kind of policy; no one could justify the human consequences or the tremendous waste of taxpayer dollars. Yet, that is exactly the policy Congress embraced when slashing Medicaid funding, even while calling for court intervention to save Mrs. Schiavo's life.

Nobody in Congress rushed to give Schmidt access to the federal courts when he could no longer gain access to his medication. There was no moral outrage over his death - or the deaths of thousands of other Americans who die each year unable to afford timely access to healthcare. It is very much like high-level bombing where the pilots never see the faces of the people who suffer because of their actions.

Schmidt was a statistic - one of the millions of Americans who had no way to pay medical care. The cause of his death was not as dramatic - and therefore not as newsworthy - as the plight of Mrs. Schiavo. But it was no less tragic because it went largely unreported.

This nation, its political leadership, and its media need to be willing to express the same concern and invest the same energy in ensuring that all Americans have timely access to needed care that they do in responding to the plight of highly visible individuals. Until then, the crisis in our healthcare system will continue to deepen. If indeed we claim to be a society guided by moral values, then surely we cannot apply them selectively.

John A. Kitzhaber, a physician and former governor of Oregon, is the director of the Center for Evidence Based Policy at the Oregon Health Sciences University.

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