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April 27, 2011

"How far should prison health care go?"

The question in the title of this post is from the headline of this local piece prompted by a recent New York story involving an imprisoned rapist in line for a heart transplant (blogged here).  Here are excerpts from the piece:

Kenneth Pike, a 55-year-old state prison inmate doing an 18-40 year sentence for raping a 12-year-old girl, saved everyone a lot of ethical angst when he decided to turn down a heart transplant at public expense.  But the issue is still out there, and it seems like only a matter of time before we’re confronted with it again.

Pike had been flown last week from his prison in Coxsackie to Strong Memorial Hospital in Rochester for a transplant evaluation.  If he was approved, the state would have been on the hook for an operation estimated at close to $800,000.  But his sister said Monday that in light of the public debate his sitation sparked, he decided against it.  Another relative said he will probably die without the transplant.

The situation prompted state Sen. Michael Nozzolio, R-Fayette, to call for a hearing to review transplant policies. No date was immediately set for it.

The episode raises all sorts of difficult questions: Should society pay such extraordinary costs for a prisoner, let alone one who committed such a heinous crime?  Does it depend on the crime?  Where is the line?  Does it depend on the cost?  How do you define “too expensive”?

Should an imprisoned rapist be in line for a transplanted organ that could go to someone leading an honest, productive life?  If you say no, are you headed down a path of weighing these decisions on the basis of a person’s productivity or value to society?  Who makes that call?  What about people committed to state mental institutions or under state care for disabilities?...

One last thought: are you an organ donor, and has this given you second thoughts about that choice?

Dare I joke that in prisons, the one place that persons get universal single-payer health care, we might soon need to have death panels to help sort out just who should and should not get expensive health care?  I wonder what Sarah Palin or others  have expressed concerns about government-run health care might think about the use of death panels in this government-run-health-care setting?

April 27, 2011 at 08:18 AM | Permalink

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It was my understanding that, due to limited number of organs available, that there were restrictions on recipients that are pretty severe: previous drug use, general health, ability to care for oneself after surgery. I would have thought many of the restrictions would have been an automatice DQ for a typical inmate.

Posted by: Ala JD | Apr 27, 2011 10:59:56 AM

This story is an apt reminder of why government control of the delivery of health services, to prisoners and ordinary citizens alike, is frought with trouble. The trouble can be called death panels, rationing, cutting back "overutilized" services (i.e., the one you need to stay alive), eliminating "waste" (ditto), or what have you. But under whatever name, trouble is what it is.

Posted by: Bill Otis | Apr 27, 2011 12:29:34 PM

"government control of the delivery of health services ... is frought with trouble"
Works pretty well in many, many countries.

Posted by: anon | Apr 27, 2011 3:15:01 PM

anon --

Thanks, but I will take health care as it has been delivered in the United States. So have people from "many, many countries," who, if they are able, come here to get health care in preference to that provided (or often not provided) in their own nations. This ranges from super-rich Middle Eastern potentates to immigrants (legal and illegal) from Mexico.

Posted by: Bill Otis | Apr 27, 2011 5:51:53 PM

"Thanks, but I will take health care as it has been delivered in the United States."

I'm sure your government-sponsored health care was just dandy.

Posted by: anon e mouse | Apr 27, 2011 6:36:48 PM

anon e mouse --

"I'm sure your government-sponsored health care was just dandy."

Yeah, just like you're sure Timmy McVeigh was innocent. They all are, ya know.

Since you don't know me, you of course have no idea what insurance I have. It's true that, in the last millenium, I was an AUSA, and at that time (and now, I believe), the feds, like the huge majority of PRIVATE employers, subsidize, as part of employees' compensation package, health insurance premiums with PRIVATE INSURERS, which is what I had. Had government insurance been available, which it was not, I would have chosen private insurance anyway.

Gotta problem with that? Or do you think government employees should not have the same private insurance options available that private employees have? If so, why? And if so, does that extend to public defenders as well?

As if it were any of your business -- much less relevant to the subject here -- I have insurance available through my spouse, who works for a non-profit, not the government.

P.S. Other than your odd, ad hominem interest in me, do you have any substantive, analytic rebuttal to a single word I have said on this thread? What would that be?


Posted by: Bill Otis | Apr 27, 2011 7:03:05 PM

@ Bill:

"This story is an apt reminder of why government control of the delivery of health services, to prisoners and ordinary citizens alike, is frought with trouble."

Not sure I understand. This case is a stark example of too few resources (I'm generally addressing the organ at issue here, rather than the monetary cost of the transplant procedure, hospitalization, after-care, including antirejection medication) to satisfy the demand (people who need a heart transplant).

When an transplant-suitable organ becomes available, it's going to go to someone and there will be some system to determine who gets it. No one is proposing letting the heart go untransplanted, e.g., because the operation would impose heavy costs on everyone else in the health-care delivery system. A system in which the organ is available for sale to the highest bidder would be one way of allocating it (great if you're a member of Bill Gates's immediate family; still pretty good if you're a friend of the Gates family; not so good if don't have ready access to a few million dollars); but I very much doubt that society would stand for that kind of allocation method.

So there's a system that tries to employ income-neutral criteria, so as to generally allocate organs on the basis of whose need for the organ is the most immediate and whose medical prognosis with the transplant would be the best. One way or another, the allocation system has to make **some** kind of decision with regard to this person and others who are convicted of serious crimes and serving long, or lifetime, prison sentences. You could have a system in which the person is disqualified; you could have a system in which their status as a incarcerated felon is given some kind of weight in the assessment of their suitability as a candidate (a thumb on the scale); or you could have a system that says the person's status as a felon should be treated as entirely irrelevant. But someway, somehow, some person somewhere is going to have to make that judgment -- it doesn't just happen.

Posted by: guest | Apr 27, 2011 7:07:28 PM

guest --

The current governance of organ distribution is undertaken by UNOS (United Network for Organ Sharing), which is not an agency of the government.

As long as there is an organ shortage, decisions will have to be made, that's for sure. The current UNOS criteria are medical need (how close to death is the recipient); biological compatibility between donor and donee; and donee's prospective ability to tolerate the operation and survive with the new organ. There are others as well, but that's the main stuff.

It has nothing to do with income, and -- even better -- nothing to do with politics, which is the shadow decider for the government.

It does have something to do with lifestyle, however. Prospective recipients are checked for drug and alcohol use, HIV, and even psychiatric stability, since each of these affects the patient's probable success or lack thereof after transplantation.

Posted by: Bill Otis | Apr 27, 2011 7:22:13 PM

Sorry but prison healthcare has a minimal relationship with public healthcare and an even lesser one with private healthcare. Have a cavity in prison, wait 3 months to even see a dentist and the remedy is complete removal. Don't even try to imagine what is involved when a real medical health issue is involved. Reality is stranger than fiction.

Posted by: James | Apr 27, 2011 7:25:21 PM

After reading another post about "Head in the Sand" regarding prosecutorial misconduct, how fair is it to deny medical care to someone who would be able to get it if they were not in prison. Obviously there are a lot of people getting released after being in prison for years who have been found innocent. There are also people in prison, like Famm's featured case of Orville Wollard. He got a 20 year man min for trying to protect his family. Should he develop health problems and need a transplant in year 15 of his sentence, what do we say?

Posted by: anon2 | Apr 27, 2011 7:29:27 PM

@ Bill:

I know; my point was just the simple point that UNOS is an agency that necessarily has rules and principles, promulgated by people, that govern who receives scarce resources and who may die waiting -- even though it's not "the government." (In the same way, insurance company employees make decisions today about whether to approve important procedures for their policyholders -- even though the insurance companies and their employees aren't the government.) That's all I was trying to say; even if it's not the government, someone is deciding, according to some type of criteria.

Posted by: guest | Apr 27, 2011 8:14:54 PM

"This ranges from super-rich Middle Eastern potentates to immigrants (legal and illegal) from Mexico."

Respectively speaking... Health care for the rich! Health care for the uninsured driving up costs in our private system! Yup, sounds like a great system to me. Great point there, Billy-O.

Posted by: anon | Apr 27, 2011 8:49:10 PM

anon --

When people from across the world, rich, poor and in between, are voting for their feet to seek health care in the United States rather than where they live or could get to, then, yes indeed, it is a great system. Their actions speak louder than your words.

It really wouldn't hurt you to be grateful for what we have in this country rather than trash it so relentlessly, ya think?

Posted by: Bill Otis | Apr 27, 2011 10:58:50 PM

Correction: "...voting WITH their feet to seek health care in the United States..."

Posted by: Bill Otis | Apr 27, 2011 11:30:13 PM

This story is an apt reminder of why government control of the delivery of health services, to prisoners and ordinary citizens alike, is frought with trouble. The trouble can be called death panels, rationing, cutting back "overutilized" services (i.e., the one you need to stay alive), eliminating "waste" (ditto), or what have you. But under whatever name, trouble is what it is.

Delivery by private insurance companies faces the same problems of scarcity, except that, in addition to the constraints on government delivery, insurance companies (a) have a profit incentive to deny care, and (b) aren't accountable to anyone but their shareholders. We see this in action every time an insurance company denies care because some non-doctor decides that the costs outweigh the benefits, every time someone with a pre-existing condition can't get insured on the individual market, every time an insured patient gets cut off after reaching a lifetime limit, etc. If you're looking for death panels, that's where they are.

There's much to be grateful for about American health care, if you have access to it. My wife and I have been the beneficiary of it on several occasions, so it would be ungrateful of me to complain. However, far too many people don't have access -- and even for those who do, our system is weighted far too much toward palliative care and not enough for preventive care. If you compare the life expectancies (and, even more critically, healthy life expectancies) of the United States and other industrialized nations, it appears that the rest of the First World delivers results that are at least as good.

There are many things free markets do more efficiently and effectively than the public sector. Health care isn't one of them, because supply is cartelized and demand is effectively unlimited. If we're going to stay private -- and I have no ideological preference for the public sector, only for what works -- then the German-Swiss-Dutch public utility model should probably be what we adopt, not the haphazard and often-cruel system we have now.

Posted by: Jonathan Edelstein | Apr 28, 2011 7:41:47 AM

To elaborate further (which is an unfortunate vice of mine):

Demand for health care is demand for life itself, and is thus effectively infinite. Supply, on the other hand, is finite, at least until we invent a single-shot immortality pill that also confers immunity from accidents.

This leads to two things. First, free markets can't price health care efficiently, because individuals will place more value on their lives than the market would. I'm certain that the market wouldn't value the life of a typical 60-year-old at anywhere near the cost of keeping him or her alive until age 70. To the 60-year-old in question, however, life is far more valuable than the cost of health care, because to that person, life is not fungible.

Second, demand will always exceed supply, so there will always be problems of scarcity and rationing no matter what distribution system is used. The question isn't whether rationing will be done but who will do it and how.

Historically, rationing has been done by wealth -- if you could afford the doctor's fee, you got health care; if not, then you went to a charity hospital (from which you might emerge alive with a great deal of luck) or went without. Insurance has modified this rationing system somewhat by enabling economies of scale, allowing the healthy members of large groups to subsidize the sick ones, and shifting some of the burden onto employers. However, for those who don't have employer-provided health insurance and are thrown onto the individual market, wealth rationing is still in full effect -- and even the insured are subject to rationing through lifetime caps, rescissions, and cost-driven decisions to deny care.

A public social-insurance system would inject politics into the rationing system where there is now none. However, the experience in countries with social insurance, or with limited American social-insurance systems such as Medicare, shows that politics almost never enters the picture in individual cases, only in categorical determinations. And personally, I'd rather have such decisions made politically than by private-sector bureaucrats, because the political system is at least somewhat accountable.

Overall, I would probably favor the German-Dutch-Swiss quasi-private system over single-payer, although both have points in their favor. I can't think of any defense of the way health care is distributed in the United States -- it's neither efficient nor humane. The care itself is, as you say, excellent, but if a fifth of the country can't reliably get it, the system is broken.

Posted by: Jonathan Edelstein | Apr 28, 2011 12:52:47 PM

Jonathan, you sir, are very wise indeed.

" if a fifth of the country can't reliably get it, the system is broken"

But Billy-O isn't among that fifth, so he chastises me and you for not being more "grateful."

Posted by: anon | Apr 28, 2011 3:24:57 PM

anon --

1. You are correct that Mr. Edelstein is a thoughtful and informed man. I believe he underestimates the poisonous effects politics will have in rationing, partly because categorical political selection will be both more rampant and more insidious than he believes and the biases will be well hidden, making accountability largely illusory.

2. If you're waiting for me to apologize for being among the four-fifths who arranges to pay his own bills, rather than dragooning my neighbor to pay them for me as if he were my slave, you'll be waiting a long time.

3. And yes, gratitude for what we have in this country is a more becoming attitude than sticking up your royal nose at the institutions your forebearers built up and you're squandering with debt and feckless self-indulgence.

Posted by: Bill Otis | Apr 29, 2011 2:47:46 AM

"If you're waiting for me to apologize for being among the four-fifths who arranges to pay his own bills..." -- Bill Otis

To claim that only people who are fiscally irresponsible are the ones who can't reliably obtain health care is probably the most arrogant, ignorant comment I've seen you make on this blog lately, Bill. But I suppose we should expect nothing less.

Posted by: centrist | Apr 30, 2011 12:15:14 PM

centrist --

It is a sign of how far things have gone when it's considered arrogant to expect to pay your own bills.

What am I being when I expect OTHERS to pay my bills? Mr. Nicey?

I don't know if self-reliance had a bad name when you were growing up. It had a good name when I did. In this family, it still does.

I have absolutely no claim on my neighbor's property, nor he on mine. That is an essential component of freedom. There is a name for claiming by right the fruits of another's labor: S-L-A-V-E-R-Y. The country went to a good deal of trouble to get rid of it.

Posted by: Bill Otis | May 1, 2011 3:20:42 PM

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