Medical hurricane: Health care reform and hepatology
Authors: Michael Charlton
Journal: Hepatology (2009)

He must, more than once, have looked in the mirror and seen his yellowing eyes and hoped it would be better tomorrow. He felt well, as patients with Wilson's disease often do, and had done since he was diagnosed by one of my colleagues. This well-educated young man moved to Las Vegas for work and found himself, in an ailing economy, unable to afford his medicine or health insurance. The patient had left our clinic with a prescription for trientene and a follow-up appointment. He kept neither. His diagnosis meant he was unable to purchase health insurance and he clearly did not fully understand the importance of taking his trientene. When I received the call requesting to transfer him for consideration of urgent liver transplantation he had been in stage IV hepatic encephalopathy with profound cholestasis and progressive coagulopathy for several days. His intensive care team had been trying to transfer him to a liver transplant center since his admission. We were not the first choice. Indeed, prompted by a family member who was aware of the patient's history of being seen by us as an outpatient, we were the seventh center to be contacted. Six centers of greater proximity had all declined to accept the patient in transfer because of his lack of insurance or other resources. I accepted the transfer request, fully aware of the lack of insurance. The patient died of intrapulmonary hemorrhage shortly after arrival (no happy ending or crowing in this story). Liver transplantation, a procedure that represents a pinnacle of biomedical achievement, offered a 90% potential for cure. Our patient died because of the type of health care rationing that occurs every day to so many of this nation's uninsured—rationing on the basis of financial resources. To some, the withholding of life-saving medical treatment on the basis of resources may seem fair or acceptable. Ironically, the same people would probably applaud the deployment of every reasonable resource to rescue our patient had he been trapped in a mine or been lost at sea. Those who fear rationing of health care should know that it occurs already and on a great scale. Although lack of health insurance is often portrayed as a choice or a gamble taken by the healthy, in my experience the decision to forego health insurance, as our patient illustrates, is borne of competing, more immediate economic necessities, such as shelter and food or by overwhelming cost of insurance due to preexisting conditions. GDP, gross domestic product; HCV, hepatitis C virus. Hurricane Katrina was a natural disaster. The subsequent rescue effort, or, more precisely, the initial lack thereof, was a national disgrace. The poverty of thought, planning, and initiative that characterized the early response was shocking and enlightening in equal measure. Katrina had, in effect, held up a mirror that reflected, for that moment at least, an image of our society and what we were and were not prepared or able to do to assist our least fortunate members in a time of crisis. The reflected image was not attractive. Eventually help arrived, although the relief effort looked more like an armed invasion at times, but a lasting impression had been made and a clear message sent: If you need to and you can, save yourself. And so it is with our current approach to health care. Illness moves among the uninsured like a hurricane, leaving a trail of distress and poverty. Among persons under age 65 years, more than 40 million (17%) do not have any health insurance coverage.1 The most common reason for lacking health insurance is cost.1 Perhaps not surprisingly, in multivariate analyses, continuously uninsured individuals are >60% more likely than the insured to have a major decline in their overall health over a 4-year period of follow-up.2-5 In 2007, medical costs were the primary basis of 62% of personal bankruptcy filings.1 Twenty-five years ago, the figure was only 8%. Importantly, more than three-quarters of people (and thus families) who file for medical cost-related personal bankruptcy have health insurance at the time of filing.1 The average out-of-pocket costs for medical bankruptcy filers are $18,000 for those with private insurance and $27,000 for the uninsured.6 According to the U.S. Census Bureau,7 the median household income in the United States, before tax, is $50,740. In other words, most families in the United States are only a major illness away from financial ruin, even if they have private insurance. If we did not have a health care insurance system and had to choose one from a long and diverse menu, it is inconceivable that we would choose the one we have. The endurance and vigorous defense of our status quo prompts the question posed by Cicero; "Qui bono?" (who benefits). The answer, of course, is complex, but includes our cadre of medical insurers, who are unburdened by our desire for health, a prerequisite for our pursuit of happiness. For-profit insurers have a responsibility to their shareholders and owners to maximize return on investment. Success, by necessity, entails the avoidance of "medical losses", such as paying for our patient to undergo liver transplantation. Our fee-for-service medical delivery system has endured because we also have a fee-for-service lobbying system. National health care spending in the United States is expected to reach $2.5 trillion in 2009, accounting for 17.6% of the gross domestic product (GDP). By 2018, national health care expenditures are projected to reach $4.4 trillion. It is not clear that the world's creditor nations, of which we are emphatically not one, will have this much money to lend us even if they think it is a good investment. Like an alcoholic who has for years been unable to recognize the consequences of dependency, we are, at last, experiencing a national moment of clarity. At the highest level, our choices have narrowed. We will change our health care system or we will follow General Motors into bankruptcy. Borrowing more money to allow continuation of our current system can only delay and make more severe the inevitable change. Proponents of the status quo, who presumably rush between global warming denial and flat Earth conferences, seem at last to be facing defeat. What does any of this have to do with our society's beloved journal, HEPATOLOGY? Nearly everything. Although our delivery system may need more tinkering than a 1970's Fiat, innovations and advances made by the physicians and scientists of our biomedical community point to great strengths of many aspects of our medical system. Indeed, a priority for any new health care delivery system must be to preserve the productivity and innovation that exists. The current resource-based rationing of health care devalues all medical advances. All of the effort and ingenuity that has led to the present success of liver transplantation was, for example, worthless to my patient with fulminant Wilson's disease. We stand on the brink of greatly improved therapies for hepatitis C virus (HCV) and have already witnessed logarithmic progress in our ability to prevent and treat hepatitis B virus infection. The primary determinant of the extent of resource-based rationing now and in the future is expense. We manage to spend 17.6% of the world's largest GDP and still leave one in six citizens without insurance. The biggest problem is cost, driven by, among other factors, overuse and misuse. As a group, we physicians spend health care dollars with too little regard for effectiveness. Every time we continue to treat virological nonresponders to HCV therapy beyond 24 weeks, for example, we diminish the pool of resources available to treat those who will benefit from therapy. Examples of diagnostic and therapeutic frivolity are endless. And we all do it. My patient, whose story I began with, demonstrates that effective medical decision-making for one patient equates to access to medical care for another. There can be no more important role for the American Association for the Study of Liver Diseases or for HEPATOLOGY than to translate the bewildering array of new and existing knowledge in our field into effective and efficient medical decision-making. In addition to our desire to publish top tier original articles, reviews, and practice guidelines, we wish to encourage the submission of works that focus on health care reform and cost-effective medical decision-making in hepatology. If you submit such work, as always, we can assure you of a fair and expeditious review. And the gratitude of patients we haven't even seen yet.