Expensive Healthcare
April 12, 2024
This post discusses health policy, specifically how we should think about the cost of expensive healthcare for people like me. So, let’s start with a summary of my current health.
Good news: My cardiologist prescribed Amiodarone for my arrhythmia. It’s early days, but the drug appears to have stabilized my heart rate, and except for some added fatigue, I am tolerating it well. This has dramatically improved my quality of life.
But—and you knew there was one coming—there’s also a reason for worry. Here’s a summary of my cancer treatment history. A series of treatments—radiation, immunotherapy, and two courses of chemotherapy—have kept my primary tumour at bay, killed the lymph node metastases I had when I was diagnosed, and prevented the development of new metastases.
However, these treatments have not been able to destroy my primary tumour. So, there’s a stalemate between the treatments and the tumour. On balance, this is good.
However, each treatment eventually stopped working, so we had to shift from one treatment to the next. The problem is that I may be running out of treatments. And if the tumour is still alive when the last available treatment stops working, then it is just a matter of time until it kills me.
However, when I say, “We have run out of available treatments,” I mean, “We have tried all the treatments for my disease that (a) are likely to work and (b) Ontario’s provincial health insurance plan is willing to pay for.”
But you may ask, “Aren’t the class (a) and (b) treatments the same?” Put another way, “Why wouldn’t Ontario pay for a treatment that worked?” Two reasons: first, many cancer treatments don’t work that well and second, for patients like me, there isn’t much evidence about how well they work
Let’s define “treatments that work” as “treatments that have been shown to produce an average of X additional months of life,” where X is enough months to matter. The sad fact is that many cancer treatments result in only a brief increase in average patient survival time, sometimes a matter of just weeks or even days. Keep in mind that cancer treatments are expensive. For example, one infusion of the immunotherapy I received had a retail price of almost CDN$10,000 just for the drug. Canada gets a discount on that price, but still!
When we think about how confident we can be about the benefits of treatment, what matters is how many studies include patients like me and how many total patients like me have been treated in those studies.
In my case, I’m not aware of any studies of patients who, like me, have a tumour that has survived so many treatments. On that basis, we have little confidence that we know how much benefit I will get. But I can argue that I have already outlived several predictions that I have only months to live. This suggests that the benefit for me—how much additional life I can expect—may be bigger than one would expect for most other patients. Therefore, I’d argue the province should be willing to take a risk on an uncertain treatment in my case.
Let’s pause momentarily and ask ourselves, “What is the point of public health insurance?” Oversimplifying, there are two answers:
1. The Ontario Health Insurance Plan (OHIP) is insurance, a way for people to protect themselves against the risk of unaffordable health care costs.
2. OHIP is a policy instrument for improving population health and well-being.
Answer (1) is correct, assuming that OHIP has the funding to cover the essential health needs of all citizens. It’s OK if the plan spends way more on me than on other people because, through no fault of my own, my health needs are more costly than most others. Because no one can fully anticipate their future healthcare costs, health insurance spreads that risk across the population so we can all afford healthcare.
Unfortunately, the italicized assumption is false. OHIP (and the other Canadian provincial plans) does not cover all essential health services. It doesn’t cover outpatient medications, dental care, or outpatient mental health care delivered by non-psychiatrists. Why not? Short answer: the Canadian public insurance system covered the most costly services in 1984 when the Canada Health Act was passed. Forty years later, healthcare is far more expensive, and provinces are reluctant to increase coverage.
In any event, because OHIP can’t pay for everything, answer (2) is also correct: it tells us we should prioritize those healthcare services that have big effects on health and well-being per dollar spent. (How you figure out which services to fund is another discussion.
I’ve argued for years that Canada doesn’t spend enough on children’s mental health services.1 Does that mean that I should forgo, say, the next round of chemotherapy so that those dollars might be spent on mental health counsellors in Canadian high schools? That might be a good trade, but that choice is not available. If I declined further treatment, I have no idea where the money saved would go.
Nevertheless, whenever I am in the chemotherapy suite, I think to myself,
These are public dollars being spent to give me a few more months of life. I have to use those months for a good purpose.
I am not arguing that Canadian healthcare is bad compared to the US. Canadians have a better social safety net than the US: more funding for higher education, guaranteed parental leaves for children, and universal unemployment insurance. All of this is expensive, but the result is that compared to the US, Canadians live longer, are better educated, and are happier. At the same time, Americans have lower tax rates and higher disposable incomes. Canada makes a better choice here.
Have you ever read Vinay Prasad on cancer screening?
Here's his latest: https://open.substack.com/pub/vinayprasadmdmph/p/why-you-should-not-get-a-whole-body?r=lobko&utm_campaign=post&utm_medium=email
I am curious as to your take on this aspect of preventive care.
What a wonderful closing, Bill. Totally you.