I find it interesting that what you believe in so strongly ultimately falls down to a cost effective analysis. Why stop there, lets stop treating all non-compliant patients while we're at it because thats clearly not cost effective.
Cost-effective arguments ultimately fall down to value for the healthcare dollar. There is an opportunity cost for everything. We have to consider the fact that we are victims of our own success in that the expansion of medical technology will bring services that society cannot possibly afford to give everybody. On the other hand, we recognize a positive right to basic education as it is necessary for the functioning of our society. The idea is
equality of opportunity, by at least partially offsetting accidents of birth in terms of wealth or genes. This is easily applicable to basic healthcare as well.
So the government ought to cover the most cost-effective and necessary things, without the implicit assumption that absolutely everything will be covered. Our individualism in America ignores the fact that we cannot insulate ourselves from the health costs of the poor and uninsured even if we didn't care about them. So giving cost-effective care to everybody to make our society more productive and humane simply makes sense on every level.
From a sociological and epidemiological perspective, compliance is a real problem. But good policy would seek ways to maximize compliance while causing minimal suffering, and what you imply would do neither.
And old people, certainly not cost effective. Are you going to send everyone with cancer straight to hospice too as thats certainly more cost effective then those expensive cancer drugs and surgeries. Medicare is certainly not cost effective, old people en masse don't contribute that much to society (although as retirement times seem to be getting later, this is not as true).
The moral imperative of beneficience does suggest that scarce resources should be allocated in such a way that maximizes the benefit for patients. Moral imperatives often come into conflict, and it becomes a matter of balancing them. It is true that one cannot expect to produce a lot of QALYs in geriatric care, but it is difficult to place an absolute value on the sanctity of individual lives. One can go overboard on any principle. We respect patient autonomy and give it substantial weight, rightly so, but not to the extent that we have a moral obligation to render futile care that the patient refuses to believe is futile. But when the care is decidedly
not futile, a 65-year-old can recover and have a meaningful and productive second life after retirement. Many seniors will find that they are happier if they find productive and personally meaningful pursuits even if they aren't in the workforce.
With Medicare in particular it is a matter of justice. Medicare is a social insurance model that these people paid into all of their lives, so we have an obligation to them. Their tax dollars helped fund the medical schools and universities that make life-saving treatments possible, and so they deserve to reap the benefits to some extent. It is not really their fault that our system has failed to control costs.
Yes, I'm being rather sensationalist about it but I don't trust the government to walk the thin line.
That is why I believe the government should cover the basics, but not promise to cover everything, only the highest priority items. If Lucentis is slightly more effective, but not more cost-effective than Avastin, then people who want Lucentis instead of Avastin can purchase supplemental insurance (ideally non-profit).
Why not reduce some of the administrative waste in healthcare spending ("30% of each dollar") and tax everyone to expand medicare or subsidize insurance. Seems pretty simple. If you cant support wonderful Medicare, how can you possibly support another government run program?
Much of the administrative waste is produced by our private insurance industry, particularly because they are for-profit so savings go to shareholders, rather than being reinvested in health. From the perspective of an insurance company, promoting health does not save you money, particularly when policyholders change plans so often. You may notice that the countries with the lowest overhead are single payer and have overhead that is 2% of overall costs. But it is unreasonable to expect that the government will consistently cover everything everybody may want. That is probably why 2/3 of doctors support a mixture of public and private.
Oh and
here is some big kid reading on lucentis for you to enjoy.
If you're going to be condescending, at least do so in a productive or intelligent way. What article makes whatever your point is?
Cancer survival rates are pretty tricky; they are highly dependent on the time of detection ("lead time bias"). To use the thorny example of prostate cancer, some studies suggest that the majority of males will have at least microscopic prostate cancer if they live to be 80. Given that total prostate cancer mortality is only about 3%, prostate cancer is clearly not always lethal. So, how do you figure out who will die of their disease if they are not treated? In the US, we screen pretty much everybody, but there is little to no evidence that this produces an actual mortality benefit (see NEJM 360:1310, 2009); with respect to the study you cite, all prostate screening does is lengthen the time from diagnosis to death, or increase the number of people diagnosed with a disease that has no chance of killing them. This will increase the "5 year cancer survival rate," but not in a clinically meaningful way.
As for the Nobel Prize bit, well that's just silly.
Very good points. Have you seen evidence on how significant the effect of false positives (e.g. with PSA) is, whether that leads to significant excessive treatment, and if there are any health policy implications to that?
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