Bioethics, Policy, and “Barking Up the Right Trees”

I suppose I should apologize for writing—now and before—so much about matters related to fiscal policy on a bioethics blog, but the line between them can be blurred when it comes to medicine, bioethics as a field tends to expand its own reach (excessively in my view), and, at the moment, in this election season, fiscal policy is sort of an 800-pound gorilla.

Plus, my attention today is seized by the comments of Bill Gross, the “bond king” from PIMCO, about the “fiscal gap” and the peril it presents to our nation. Briefly:
• The nation’s current total debt is $16 trillion (all numbers approximate in this post);
• The future obligations under Medicare, Medicaid, and Social Security, as they now exist, amount to an additional $60 trillion;
• The Congressional Budget Office, the International Monetary Fund, and the Bureau of International Settlements’ projections imply that, rather than just reduce our budget deficit of $1.2 trillion, we need to cut spending and/or raise taxes to the tune of $1.6 trillion per year, starting soon (as in, now), to get our national debt under control. The alternative is for our central bankers to print money until it’s worthless, and the economy collapses—not in the next presidential term, but in the next generation (10-20 years).

Oh—full expiration of the “Bush tax cuts” would yield $200 billion per year, and the “budget deal” that was said to be so close in 2011 would have yielded $400 billion per year. That is, chump change.

I’ll try to stop soon with the numbers, but if this year’s spending were where Mr. Romney says he will aim (20% of the GDP), that would have “saved” (I try to use the word advisedly, because of the emotional/political overlay of these discussions) $700 billion. If tax receipts were where Messrs. Simpson and Bowles suggested we should aim (21% of GDP), that would have brought in another $750 billion. Getting closer, but not there (but leaving a deficit lower than the 3% of GDP maximum urged by the Secretary of the Treasury). If the current, historically high federal spending ($3.7 T, 24.6%) pertained, total tax receipts would have to have been $4 T instead of $2.4 T, or 26.7% of GDP. Unheard of in our history.

Now, full disclosure: I’m sort of a Paul Ryan fan. But I do believe I am open to “compromise,” and yet, with all the bipartisanism (and grace) that I can muster, it seems to me plain on its face that the U.S. government simply must spend less on health care going forward. I want to believe that approaches like Mr. Ryan’s offer prospect for real reform. On the other hand, “Medicare as we know it” (a rhetorical phrase that spikes my blood pressure) will, if not substantially changed, collapse in my likely lifetime. Or, as Mr. Gross fears, the country will.

Mosey on over to the Hastings Center’s “Over 65 blog” and one can read poignant and thoughtful posts about the physical and financial frailty of old age, alongside rhetorical flourishes against the likes of Ryan, written by Dr. Theodore Marmor (public policy professor emeritus from Yale, single-payer advocate). To be fair, I need to dig deeper, and I’m going to try to study Dr. Marmor’s arguments in a recent “point/counterpoint” series on Medicare reform. But from the little bit I’ve read so far it seems that the most thoughtful people’s positions are entrenched enough that compromise is out of reach not just of our politicians, but of our populace in general.

For the moment, my thought is that the predominant “bioethical” issue for the foreseeable future, at least in the U.S., may be how on earth, if we indeed go “off the cliff,” to handle the care demands of my generation. I wonder if it won’t make worrying about matters like stem cell research and human enhancement seem like luxuries.

And it seems to me that much thinking about this—including several of my past posts on this blog—fail to begin to address the deep shock that will be coming to how we live out our days, how we view our earthly estate, and how Christians can lead the way.

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Joel Goodnough, MD
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Joel Goodnough, MD

Very well said. I think we need a new approach to paying for healthcare based on free market principles that give the consumer choices. But that can’t happen without cost transparency, insurance reform, and tort reform. If I go to the ER with a severe headache I will immediately get a CAT scan. No one cares or even knows about the costs because insurance covers it. I am not given the information I need to make any decision as to if, where, or when I want to have that CAT scan done. And the doctor and hospital are not give… Read more »

Jon Holmlund, M.D.
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Jon Holmlund, M.D.

Dr. Goodnough, I agree with you, although I hasten to add that many of our fellow citizens (including many brothers and sisters in Christ) would resist the “free market” approach based on arguments that are cogent even though I disagree with them. That said, your example (which I also agree with) is relatively easy. I would venture it fits into the “wasteful care” category which people like Dr. Berwick and Dr. Emanuel have argued is enormous indeed. My worry is that the differences of opinion on whether Medicare needs fixing, and if so, how, are so deep, and the tendency… Read more »

Joel Goodnough, MD
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Joel Goodnough, MD

You are correct. Under our present system allocation decisions will become a common headache. It really is a mess and we don’t have the will to make the necessary changes to fix it. Our future elderly can pay for their knee replacements if they are encouraged, through education and tax policy, to save for it early in their working years and if the cost of the surgery comes down through competition. Their inexpensive catastrophic insurance policy would cover unexpected emergencies. Properly regulated free market principles with an appropriately sized safety net work well. Charities can fill in the gaps. Thanks… Read more »