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We've been rationing care all along

New York's hospital capacity is about 53,000 beds,

New York's hospital capacity is about 53,000 beds, with around 3,000 being specially equipped ones for intensive-care. The state estimated this week that New York will need between 55,000 and 110,000 beds, and perhaps as many as 37,200 ICU beds as the coronavirus crisis peaks.  Credit: Getty Images/baona

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The coronavirus pandemic has turned the issue of healthcare rationing — usually the domain of philosophers and bioethicists — into a front-page news item and a matter of widespread public concern.

Not a day passes without dire warnings that hard-hit communities will witness shortages of ventilators and intensive-care-unit beds, leading to a grisly life-and-death triage for patients in dire need of artificial respiration. But it is a mistake to view this scarcity as a result of the current crisis. Rather, this shortage of medical equipment and clinical personnel is better thought of as a symptom of a rationing system that started long before COVID-19.

Public health experts often distinguish between “visible” victims and “invisible” victims. The former are patients who will know if they are denied care. For instance, Arizona’s Medicaid system briefly stopped paying for certain high-priced organ transplants in 2010; the “visible” victims of this policy protested and the decision was reversed. In contrast, those same funds might have been spent on early-detection programs and preventive health measures like mammograms and smoking cessation therapies, saving many more lives. However, patients who die from breast or lung cancer many years later because these interventions were never offered do not view themselves as victims of care denial. They are “invisible” victims in this regard, even to themselves. Visible victims exert political pressures that invisible ones cannot, so with rare exceptions, our health care system is designed to favor the welfare of the former.

The consequences of this approach are apparent in the current pandemic. Patients suffering from high blood pressure, diabetes and respiratory illness suffer much higher rates of morbidity and mortality from COVID-19 than their healthy peers. According to the Centers for Disease Control and Prevention, patients with underlying medical conditions account for the vast majority of coronavirus hospitalizations. Early data suggest that these patients are four times as likely to require ICU beds and nearly six times as likely to need ventilators. In short, if most Americans were in good health, we would likely have enough ventilators and ICU beds to meet our needs.

But the underlying conditions that increase the need for ventilators are largely preventable. Severe illness with COVID-19 is often the product of obesity, smoking, social isolation and lack of access to routine outpatient care. In ordinary times, shifting healthcare dollars toward preventing or treating these conditions and away from high-budget, low-efficacy medical interventions has been shown to save many lives. This approach forms the basis of the Oregon Health Plan, first adopted in 1993, a novel and largely successful attempt to ration health care dollars rationally in a manner that reduces the number of invisible victims. As a result, low-income Oregonians are healthier. Their state was recently able to send surplus needed ventilators to New York.

Ironically, the victims of our long-term system of irrational rationing might be COVID-19 patients previously in perfectly good health who are now forced to compete for ventilator space and ICU beds with patients suffering from preventable hypertension and diabetes. In that sense, we really are all in this together.

Our nation will inevitably face future pandemics. While increased surveillance and preparation are essential, our best defense to crisis rationing is not hiring more contact tracers and stockpiling more ventilators. Rather, the solution might lie in allocating health care resources more rationally in quiet times, so rationing during the next health care emergency will not be necessary. 

Dr. Jacob M. Appel is director of ethics education in psychiatry at the Icahn School of Medicine at Mount Sinai. He is the author of “Who Says You’re Dead?,” a collection of ethical conundrums.

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