Health Affairs Blog: A Narrative On Narrative Matters

by Richard Lamm

an excerpt

The human animal is a caring animal, and many of the narratives we were celebrating didn’t require more resources: a little more understanding, a change in attitude, a smile, a little more time listening. The purpose of Narrative Matters is to tell a compelling story and show that health policy has human consequences and that should not primarily be about budgets. Yet…

Loving your neighbor is not a distributional issue but subsidizing your neighbor is. The challenge of modern medicine is to see the inevitability and desirability of forming procedures and strategies that fit infinite demand into finite resources. In 1988, Oregon State Senator (later Governor), John Kitzhaber was called “Dr. Death” on the front page of the Denver Post. Kitzhaber, a physician/legislator was instrumental in developing the Oregon Health Priorities system. When Medicaid funding for transplants ran out, Kitzhaber suggested that Oregon shouldn’t fund high-cost transplants until all women in Oregon had prenatal care. He soon expanded this thinking to apply to all Medicaid monies and to suggest that basic health care should be funded before some high- technology procedures. Oregon decided to ration benefits instead of people. Kitzhaber’s metaphor was “to get everyone in the tent, even if we have to thin the soup.”

Then an 8-year-old by the name Coby Howard presented to the system his need of a bone marrow transplant for a long-shot chance to put his leukemia in remission. Oregon didn’t back down, and Coby Howard died on the front page of many of the nation’s newspapers.

The same year, California voted to pay for transplants (Why should they take that kind of heat?); then one week later, California knocked 270,000 low-income women off of their Medicaid program. This action was examined in a couple of health journal articles that showed clearly that California’s action resulted in much more mortality and morbidity. But it was not controversial. The United States is well practiced in leaving people out of the system.

I was reminded again and again that the devotion of a physician to his or her patient is a key foundation of most health care systems, here and abroad. One physician gave me a 20-minute exposition about not making him the rationer. Rightly so. For two thousand years physicians have been patient advocates. But how do we fit that into a world of limits, I asked. It wasn’t his problem. Correct, but it is our problem as Americans.

Read More