WASHINGTON, D.C.—Recently, the American College of Physicians, the second-largest group of  U.S. doctors after the American Medical Association, has argued in favor of the position that doctors consider cost-effectiveness when deciding how to treat patients. It has gone so far as to include the recommendation in its latest ethics manual. Due to healthcare costs in the U.S. that are twice those of other industrialized countries, they argue that:

“In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches.”

This is a dangerous precedent as doctors should be seeking to provide the best healthcare to their patients, not making decisions about how to ration care by deciding who should receive which procedure or medicine based on cost. They are not qualified to do so, and it is professionally and morally inappropriate. This can and will lead us down the road to healthcare rationing and will have a disproportionate impact on underserved populations such as African Americans who do not typically have the funds to spend as much on healthcare as other groups. Studies have shown that African Americans receive less healthcare than White Americans, particularly when the care involved is expensive, lifesaving new technologies. This situation will be exacerbated with health rationing based upon cost considerations.

As the Rev. Anthony Evans states: “We are not saying that cost should never be a factor, but given the history of disadvantages African Americans have had we need to see preventive care, drug therapy, the latest scientific therapies and procedures and health maintenance over the next 30 years to reduce significantly African Americans’ horrible health personality and to raise the life expectancy, especially among Black males over the next 10 years.”

A critical flaw in the American College of Physicians’ argument is that they believe that you can reduce healthcare costs through rationing. This is simply not the case. The  critical driver of healthcare costs is the fact that the U.S. has a for-profit healthcare system with massive overhead and administrative costs since a private sector middleman is required and there is a great degree of fragmentation among the myriad healthcare providers that prevents the economies of scale evident in other countries. 

The classic comparison is between the U.S. and the UK, which have similar legal systems and economic structures. The U.S., with its for-profit health system spends about 15 percent of its Gross Domestic Product [GDP] on healthcare annually while failing to cover 50 million people. In contrast, the public National Health System of the UK spends about 8 percent of GDP on healthcare while covering 100 percent of the population. The differences are startling and can only be addressed through fundamental structural change in moving the U.S. healthcare system to a greater focus on public good rather than private profit.

Amazingly, as part of its argument in favor of having doctors factor cost considerations into healthcare considerations, the ACP is actually quite extreme and explicit in favoring what is tantamount to stinginess:

“Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”

The use of the term “parsimonious” goes far beyond having doctors be more efficient in what they proscribe but implies that doctors be cheap and withhold care for particular patients. Your doctor should be concerned about your health, not about your ability to pay. Doctors obtain MDs not MBAs, so they are simply not qualified to make these decisions. Moreover, trust is an important part of the doctor-patient relationship and it will undoubtedly be undermined if patients believe that they may have been offered a procedure based upon cost rather than effectiveness. As the Tuskegee experiments demonstrate, racism is as rife in the healthcare system as it is in all other aspects of American life, so there is little doubt that the use of cost as a criteria for health decisions will open up a new avenue for discrimination.

As the saying goes, an ounce of prevention is worth a pound of cure. For that reason, the National Black Church Initiative is calling for $25 billion to be spent on prevention and primary care in the United States. That would do far more to improve healthcare outcomes than healthcare rationing.

The NBCI cannot support recent efforts to take costs into consideration when determining a patient’s eligibility for healthcare procedures. Healthcare costs are rising in general are expensive but nonetheless lifesaving technologies should not be denied to Americans based upon their cost. These kinds of standards have the potential to be highly discriminatory and would serve to provide the healthcare industry with a powerful tool to deny much needed healthcare to citizens at a time when we are trying to expand health coverage to the more than 50 million uninsured Americans. The whole point of national healthcare is to avoid the de facto healthcare rationing that has become part of the dysfunctional healthcare regime in America. Cost-based standards should not be a factor in determining access to healthcare. 

The National Black Church Initiative

About NBCI