Taking death panels seriously

post by Bill Gardner

One of the important decisions that will be made across the US in the next years is whether states will expand Medicaid coverage to include more uninsured patients. The Affordable Care Act provides increased federal funding to do this, but the decision in National Federation of Independent Business v. Sebelius permits states to refuse to expand Medicaid and cover these patients.

There are many things at stake here. Randy Barnett thinks that the ACA expands the power of the federal government. Tyler Cowen (@tylercowen) points out that spending more state revenue on Medicaid may require spending less on education or other desirable programs. Josh Barro (@jbarro) argues that taxation to expand public spending on health care creates significant dead weight losses of utility.

What is also at stake are some of the lives of people who would be covered by Medicaid if coverage expanded. To see this directly, consider what happens when a state contracts Medicaid coverage, as is happening in Arizona. A surgeon, Randy Oppenheimer, has made a video in which some of his patients -- working people who lack insurance and do not qualify for AZ Medicaid -- talk about the consequences of being uninsured. I warn you that the video includes disturbing images of cancer.

It's not my view that Oppenheimer's video makes a definitive case for expanding Medicaid coverage. Expanding Medicaid might rescue these patients, but what else would it do? Are we sure that Medicaid expansion would, when all consequences are registered, save lives? I expect, for example, that Barro would argue that the economic gains from reduced taxation would extend lives; perhaps even more than would be saved through the expansion of Medicaid. So it is not my view that Barnett, Cowen, or Barro are apologists for killing.

What I want is for everyone to see that decisions about Medicaid coverage are not simply opportunities to satisfy norms about the relationship between federal and state power or to resolve state budgets. They are also life and death decisions for human beings. Arizona has decided that having dependent children entitles you to lifesaving care, but being single does not. Look no further for a death panel.

And who was on that panel? State voters determine the extent of Medicaid coverage as much as anyone does. Do not imagine that the health care rationers are distant experts, like the to-be-named (and god help them when those names become public) members of the Independent Payment Advisory Board. The US has 50 death panels, the state electorates. We are rationing health care, we have always rationed health care, and the forthcoming decisions by the states about whether to expand Medicaid will be decisions about rationing health care. We are all on death panels, and we need to appreciate the responsibilities that come with that role.

h/t Ross D. Silverman (@phlu)