Our readers and my fellow contributors may remember, back when Obamacare was in the making, that we had some posts about the rationing implicit in aspects of the bill. In particular, we highlighted the limitation on "excess" readmissions as a probable locus of rationing. One of our liberal commentators insisted that it was not so. No rationing would take place.
Well, surprise, surprise! The board that oversees the rules for Medicare put rules in place to implement precisely that requirement (preventing "excess" readmissions), and whaddaya know? Those rules have already killed one person.
Here is the long version. The short version, as I understand it, goes approximately like this: Frank Alfisi was on kidney dialysis on an outpatient basis. He felt too sick one day with symptoms like those of a tummy bug to go to his outpatient dialysis, so he skipped it. Within a day or two thereafter he was so sick (from not getting the dialysis on schedule) that he couldn't do dialysis on an outpatient basis but needed to have it as an in-patient. But the Medicare rules said that he wasn't allowed to be admitted as an in-patient for "mere" dialysis, because dialysis alone isn't expected to keep one in the hospital for at least two midnights. So the doctors had to delay his dialysis until he had seizures and other sufficiently bad symptoms which would allow them to admit him with the expectation that he would stay at least two midnights. (I'm pretty sure he eventually got the dialysis, but the article is a little unclear on that point.) The excessive delay in regular dialysis messed him up so badly that he was never able to go home again; he suffered greatly for a month or two and died.
The idea that this was a smart move to save the taxpayer money is something of a joke. Had he been able to have his dialysis, as an in-patient, just a little late, he could probably have gone back home to living on his own and having regular out-patient dialysis. As it was, he had to be cared for in various institutions for almost two months at the end of his life, which was presumably more costly than that same period of time living back in his home as he had been before. I suppose that in a sense one might regard this as a long-run savings, since he died and didn't need dialysis treatments thereafter, but that wasn't supposed to be the point. The point of this (stupid) rationing rule was allegedly to prevent frivolous, unnecessary admissions and re-admissions to the hospital. What the rule-makers didn't reckon with is that just maybe there aren't so many frivolous admissions out there as they thought. Maybe even short-term admissions could be actually medically called for. Maybe they are making things worse for everybody by taking away doctors' discretion in admitting for, heaven forbid, less than two midnights.
As is so often the case, the peculiarly sickening nature of the two-midnight rule lies in the fact that it is not ill-intentioned. It would be easy enough to toss off a conservative pundit quip to the effect that killing Frank Alfisi and others like him was the point of the whole thing to save money long-term on his care, but I honestly don't believe that was the case. No, these centralized managers still believe that the people on the ground, the doctors and nurses, for example, don't know their business as well as the centralized managers and that the bureaucrats can force them to do better and thereby save money. The slogans vary ("evidence-based medicine," "avoiding excess readmissions") but the stupidity is fundamentally always the same: Big Brother knows best. You are being wasteful. Let us help you to be more efficient by micromanagement. But centralized control of an economic system is no more likely to work well in medicine than in the production and distribution of shoes or bananas. And so, lives are lost pointlessly.
As with so many things in Obamacare, so here: The response to the negative response by doctors has been to delay the two-midnight rule, but apparently only temporarily. Hurrah, hurrah. That just adds unpredictability to the system. I'd be willing to bet that we haven't seen the last of it. If you or your loved ones are on Medicare, you may very well run into it--who knows when and who knows where. And lots of people cannot avoid being on Medicare.
I want to point to this story as a cautionary tale particularly to the well-intentioned. This is the nature of centralized, government-run healthcare. It's not enough to say, "Oh, wouldn't it be nice if we could have government-run healthcare with people in charge who don't want to bump off patients." The fact is that centralized control works badly. This type of stupidity is inevitable. No, it wouldn't be okay if we just had "good people" running the system. No, it is not the case (as I've seen some say) that we ought to expand Medicare to more people. No, and again no. The problems with Obamacare are manifold, but one of the major ones is that it is running in precisely the wrong direction. Instead of making the medical sector more market-based, it puts more middlemen between doctor and patient. The death of Frank Alfisi is just one example of the consequences.