Yes, Virginia, there are death panels …

… in Republican-ruled Arizona.

… created, for example, by the Republican governor of Arizona and its Republican legislature. Except that there’s no actual panel: the rule is simply that if you’re on Medicaid in Arizona and need an expensive procedure to live, you die.

That’s not to say that the Arizona decision is wrong, given the fiscal constraints; perhaps there are better uses of $200,000 than paying for a single liver transplant. The alternative, of course, would be higher taxes so this particular stark choice didn’t have to be made.

Even then, it’s not obvious that every heroic procedure recommended by a physician with a large financial stake in doing it ought to be done. But that problem of medical-economic decision-making wasn’t invented by the Affordable Care Act. The lack of outcry about the Arizona situation demonstrates – were any demonstration needed – the fundamental dishonesty of the opponents of health care reform.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact:

19 thoughts on “Yes, Virginia, there are death panels …”

  1. Would it be cynical to note that this frees up said liver for a richer person too?

    Since we ration transplant organs, this will tilt the pool who can enter the organ lottery to a different demographic.

  2. From this 2008 comparative study by Dutch experts:

    ¨Estimated mean cost of a U.S. liver transplantation was US$163,438 (US$145,277-181,598) compared to US$103,548 (US$85,514-121,582) for other OECD countries.¨

    In India, medical tourism outfits will do a partial liver transplant from a living relative (not, by law, a dead Indian) for half that again.

    One of the quickest ways of bringing down US hospital costs would be to allow buying procedures abroad. The English NHS started buying non-emergency surgery in France in 2002, admittedly to reduce waiting lists rather than to save money; but it wasn´t apparently more expensive, and the NHS is a low-cost operation.

  3. Oh, there's outcry all right. It's just coming from the left, like the multiple posts here. Which demonstrates the fundamental dishonesty and insincerity of proponents of health care reform.

  4. Take that back, Fred!

    … The GOP health-care plan continues to be "be rich," or failing that, "just die then."

  5. Wealthy people have more options. That's practically a definition of "wealth". Everybody dies. Most people experience illness before death. A large fraction of health care costs are never recovered from treated patients in premiums or bills (private care) or taxes, post-treatment. Whether it makes sense to spend $X to extend the life of patient A for Y hours, days, weeks, months, or years is a value judgment. Similarly, whether it makes sense to enhance the functioning (by some measure) of a patient is a value judgment. I do not see that society as a whole gains anything when legislators transfer treatment decicions and control over medical resources from individual patients and physicians to remote authorities. Inevitably someone decides when to pull the plug. It's not a question of eternal life or not, it's just a question of who makes the call, when to pull the plug.

  6. This article in the Tucson Weekly is a fine read:

    The stunning fact is that when the AZ Teabaggers cut the funding for transplants they saved 5 million but lost 20 million in federal matching funds:

    "But there were areas in healthcare spending that were not protected by federal mandates, including certain kinds of checkups—and transplant services. So lawmakers cut about $5.3 million in state funding for those services, which resulted in the loss of more than $20 million in federal matching funds, according to Rep. Matt Heinz, a Democrat who called the cuts "unconscionable."

    Maybe its just me, but isn't investing 5 million and getting 20 back shrewd business? At any rate, what makes this dramedy even more comedic is that AX Teabaggers promise all the time to lure new business to the State. Right. With national news like this? Do these folks live in a sewer? Really, what business will come to State that lets people die? But wait it gets better. Here is a right wing Az State legislator (Antenori) getting his freak off on this issue. Again the quote is from the Tucson weekly:

    But Antenori, who voted in favor of the cuts, said the underlying problem was that government was involved in the health-care industry, period.

    "This is exactly why you don't want government in the health-care business," Antenori says. "If we had made health insurance really affordable and expanded competition so that it would come in line with the costs of car insurance, a lot of this wouldn't happen, because (patients) wouldn't have to go to some faceless, heartless, cold-blooded government bureaucrat to find out whether or not they can get a heart transplant. That's the real story that nobody wants to talk about. I honestly believe that this is cruel, and this is exactly what you get when you let the government make these decisions."

    What planet do these people live on?

    Woman may be from Venus and men from Mars…

    But Teabaggers?

    It ain't Earth baby…

  7. This is actually the second round of death panels, the first of course was when private insurers declined to cover these people for an amount they could afford. If not for medicaid the decision of the first death panels would have been final.

  8. Hi Malcolm,

    I've lived in downtown Atlanta, near MidTown, and I've lived in SF, in SOMA, not

    too far from the Castro (ignore a certain street in SOMA, on certain weekends),

    and so I thought I knew a lot of "alternative" lifestyle lingo. So it is a bit

    of a mystery to me. Why is it seemingly considered negative to accuse someone of,

    um, teabaggerery. Please elaborate. I seem to be missing something!

  9. For more on my points of AZ, cultivating bad news, and luring business away…

    Check out this post from Jon Talton:

    Here is a key paragraph:

    Arizona drew only $103 million in venture capital in 2009 and $162 million in 2008, according to Dow Jones VentureSource. Washington state, with a similar population, attracted $205 million in the third quarter of 2010 alone. Memo to the guv: VC avoids states that denigrate education and fan hatred and intolerance. In an economy that will be ever more dependent on world connections, Arizona's share of exports is just 1.3 percent of all American goods sold overseas, down from 2008 to 2009. Without chips and aircraft parts, legacy industries lured decades ago, Arizona would barely be in the game. Mexico is the state's largest trading partner, even as Anglo Arizonans despise Mexicans and state policy has actively worked to alienate this critical partner. Similarly, the state gained only 77,000 jobs from foreign direct investment in 2008. The Carolinas attracted a combined 314,000.

  10. (Mark): "The lack of outcry about the Arizona situation demonstrates – were any demonstration needed – the fundamental dishonesty of the opponents of health care reform."

    I don't see this. Everybody dies. For any amount of resources $X and for any additional increment of lifespan y there is a human so damaged that $X is insufficient to achieve y. A medium-sized US State could probably afford to purchase one band-aid and one aspirin per year for every human on the planet. The Earth's entire GDP is insufficient to keep Mark Klieman alive for ever.

    Economies of scale at the delivery end of the medical care industry end somewhere around the level of a medium-sized corporation. There is no convincing argument from "economies of scale" or "natural monopoly" for a government presence in the medical care industry. The State cannot subsidize critical care, neonatal care, or geriatric care without an operational definition of "critical care", "neonatal care", or "geriatric care". In an unsubsidized, uncoerced market in medical services, individual families face the choice: extend grandma's life another two months and go bankrupt, or pull the plug and put braces on the kids. Legally-mandated aggregation of medical decision-making create a tragedy of the commons, where individuals do not face the tough choice and the country goes bankrupt. Or some government body (a "death panel", if you will)decides to pull the plug.

    There's no mendacity or hypocrisy in saying "If you make medical care a State function, you will have death panels" and then observing: "you made medical care a State function, et voila, a death panel".

  11. Claiming procedures such as bone marrow transplants, liver transplants, lung transplants, etc. are experimental or unorthidox and therefore not in the normal relm of modern healthcare so should not be covered by health insurance is a disingenuous dodge.

    There is a difference between providing an expensive procedure with a 30% chance of success to a person of middle age and providing the same type of care to a 90 year old person. Obviously there are limits to what lengths a society can go to in the effort to prolong life. The real question being looked at here is: Is publicly provided health insurance fundamentally the same as private health insurance? When private insurance is unaffordable or made unavailable to certain individuals does society have an obligation to fill the gap? These questions are particularly pointed in a country that refuses to provide any rational controls on the costs of healthcare or health insurance and has allowed that sector to grow into the most bloated and expensive health system in the world.

    It is rediculous to talk about the practical limits of what care the public can be rationally expected to pay for or subsidize without examining the practical limits of what kinds of profits all of the players in the healthcare industry should be reasonably allowed to take in.

    Sadly the AZ situation isn't really as much about healthcare as it seems to be about making political hay by a governor bent on making a show out of rolling over the powerless so her base will see she is tough on 'those people'(read: poor and with dark skin). GOPers still don't have any ideas they are for, just more HELL NO.

  12. Fred,

    This is not about experimental treatments. Ultimately, to voters, it's about taking value judgments from individuals and aggregating them into the hands of political bodies. Is it worth doing without other goods and servicees to keep some unresponsive lump of meat at 37 C. for another year? Is it worth doing without other goods and services to replace the hip joint or knee joint of an arthritic 90-year-old? How 'bout knee joints of a professional basketball player? How 'bout a lung transplant for a nicotine addict? How 'bout a liver transplant for an alcoholic? How 'bout knuckle joints of a professional pianist?

  13. How ’bout a 32-year-old truck driver with four kids and a friend's donated liver?


    Never mind the ethics…

    Do the hard science math:

    An Arizona budget cut of 5 million that dried up hope for the 32 year old father.

    When AZ did that it meant it turned its back on 20 million matching federal funds.

    So the math says AZ refused to invest 1 dollar to get a return of 4.

    All of which would be spent on the paychecks of Az doctors, nurses, and hospital staff.

    That ain't no way to run a business…

    That ain't no way to run a government…

    A policy that sinks all boats is materialistic dumb and ultimately self defeating.

    Planet Teabag is a stunning stupid place…

    Someone needs to stick it where the sun don't shine…

  14. (Koreyel): "VC avoids states that denigrate education and fan hatred and intolerance."

    (Koreyel): "Planet Teabag is a stunning stupid place…Someone needs to stick it where the sun don’t shine…"

    Got a mirror, dickbreath?

  15. As I wrote earlier, I try to conduct a civil discussion, but I follow the example of my ethical superiors. If "teabag" and "stick it where the sun don't shine" pass, so does "dickbreath".

  16. Malcolm Kirkpatrick is a most excellent troll. I hope he sticks around

    for a while. I am certain his arguments are changing minds, all over the


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