Wednesday, November 23, 2005

Rationing Health Care by Weight and Behaviour

Heath care in Canada is an unsustainable proposition. It currently consumes over 40% of most Provincial budgets and, if left unchecked, will consume 70% of these budgets by 2015. The debate in Canada is not be about whether it should be public or private but about how we can rationalize the health care system and change the behaviour of people who find themselves in need of care.

One health care system has part of the answer. The public system will provide hip and knee replacements only if your body mass index is below 30. Above a BMI score of 30, you have to pay. That is, since the cause of most of the knee and hip replacements is obesity and this appears to be something that can be managed by diet and exercise, those who fail to manage their weight pay the consequences. This is to be implemented in Ipswich in the UK (see today's Daily Telegraph).

Taking this further, patients who continue to smoke should have to pay for lung related treatments and throat and lung cancer treatments through insurance arrangements they could make as they begin to smoke. Those who knowingly engage in unsafe sex who then contract an STD may also find themselves faced with a bill. People who cause traffic accidents because of drunk driving should pay for the full cost of treatments for all those injured by their recklessness.

Patient groups in the UK are already up in arms about the link between obesity and access to treatment. They are right to say that there are several causes of obesity, not all of them related to actions which an individual can take (e.g. genetic causes). Exceptions will need to be made. But the principle of access linked to behaviour will be one that we will find, however distasteful it may initially seem, coming to a health care system near you.

Two tier health will follow. Those who chose behaviours which are likely to cause illness will need insurance. Trouble is, insurance rates will be very high since only those who engage in such behaviour will really need insurance and they will almost certainly make full use of it. Given how expensive the insurance will be, they will prefer cigarettes, food or couches rather than insurance and will find themselves unable to cover the costs of their health care.

The downside of all of this is the new role it creates for health professionals - police men and women. They will police the system.

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