Rationing Health Care: A Policy Approach

Health care is back in the news in a big way. Yesterday President Obama characterized the GOP budget as a thinly veiled form of social Darwinism. Strong rhetoric for sure but also accurate. Republicans are slashing budgets and hurting the people with the least amount of power--people such as the elderly and disabled. Through Paul Ryan the Republicans are waging an all out war against people that are dependent upon Medicare. Republicans want to partially privatize Medicare into a voucher system. Many Americans rely on Medicare, Medicaid and Social Security Disability payments. By rely I mean use this to help pay for prescription medication and wheelchairs. We are not talking about luxuries but rather people's life and ability to function. People like Ryan are playing a dangerous game. The Social safety net is too expensive and poorly run by Washington he cries. Let the states handle it via a voucher system. What Ryan is not stating is that many states are broke. Moreover states can use the money any way they want.

After I read the President's speech I came across an article by Daniel Callahan, "Must We Ration Health Care for the Elderly" in the Journal of Law, Medicine and Ethics. Bear with me as I will get to the connection. Callahan is a major figure in bioethics. He helped found the Hastings Center and is a prolific author. He is also a kind and generous man as I have been fortunate enough to meet him. I have read much of his work and cannot make heads or tails of what he wants. Sometimes I shake my head in wonder and think he wants me and other people with a disability to be dead. We are a serious drain on the economy. Yet, there are other times when he is spot on and I agree with much of what he writes. For instance his views on technology in medicine are thought provoking and I agree with much of what he wrote in his book Taming the Beast. No doubt the health care system is overly reliant on expensive technology. For example, I think we can surely pass on expensive exoskeletons and invest heavily in wheelchair technology.

So what did Callahan have to say about rationing and the elderly? First he considers rationing to be "an organized effort by a public or private institutions (e.g., Medicare or a private insurer) to equitably limit the availability of some desired or needed medical treatments in the name of preserving the economic sustainability of the institution as a whole or equitably distributing a scarce resource." Obviously the key word here is "equitably". Callahan goes on to state:

"First, rationing should be done by policy, not by individual doctors and patients at the bedside. There would otherwise be too much variation in decision making, discrepancies between doctor and patient values, and the possibility of physician bias. Rationing must, that is, be removed from the ordinary doctor-patient relationship and shifted to the policy level. Second, policy must be set by democratic process (which could be accomplished by Congress delegating responsibility to a federal agency). Third, the policy must be carried out in a transparent way. Fourth, there should always be a provision for appeal."

I agree with his first point. I have been subjected to physician bias and it is not only wrong but dangerous. I depart from Callahan on his other points. For example, point two. The democratic process is far from equitable and people with a disability are not part of the discussion that takes place in congress. With regard to points three and four, at a theoretical level I agree. But I do not live in a world of theories. I do not believe any policy will be transparent--well maybe to law makers and lawyers but not to your average person and especially not your average person with a disability. As for appeals, great. Let me just ask how long and involved will they be? Let's say you are turned down for a high end wheelchair cushion and need to use a cheaper alternative that was considered to be adequate. You get a skin breakdown, a bad one. The skin that heals will never be the same. Never.

Callahan also advocates the use of QALY used in Britain. Quality Adjusted Life Years are economically proven to save money. Callahan stated QALY "is a leading means of assessing the cost effectiveness of a treatment. Its use requires careful evidence-based research, which in the U.S. could be provided by a federal agency. Instead of contending as I did in my book that an age would have to be specified for setting limits, I would now use QALYs to determine (but not solely) what they would be, thus using a methodological tool applicable to all age groups." Great but using QALY would establish my life has far less value than a person that can walk. Yes, my life is not as valuable as a person my age who can walk. So who gets treated? Not my crippled ass.

Ryan and Callahan are thinking at a national level. I am not such a thinker or politician. I am a grass roots sort of person. I study culture and how it affects people's every day life. From this microcosm I make observations about the lives of the people I study and where they fit in culturally. There is no doubt in my mind if Ryan's GOP budget is enacted the elderly and disabled will suffer. I am equally certain if we follow Callahan's suggestion on rationing I fear what will happen to the elderly and disabled. Most troubling is Callahan's desire to use QALY. Yes QALY will save a significant amount of money. No doubt about the savings. But at what cost are we saving? I for one do not accept the fact my life has less value than a person who is not paralyzed. Why there is even a law that states this--that pesky legislation know as the ADA. Ryan and Callahan make me shake my head in wonder. What ever happened to equality?

A Small but Important Change

This morning I was reading A Girl with a Cane, a blog I like very much. I noted she added a widget to her blog Odiogo. I down loaded this and hope it solves a long standing problem with my blog. Specifically, some people who are blind have struggled to read the content of my blog. So go ahead and click on Odiogo. Yes you can now listen to a computer generated voice read my blog via itunes. Very cool and I sincerely hope this will solve problems a few blind readers have encountered.

Equality is Illusive

This is not a photo shopped picture. I saw this image on Facebook and thought someone was having fun making a horribly wrong photo. Surely more than 20 years after the ADA was passed into law such a gross violation could never occur. This is wishful thinking at best and at worst pure fantasy. Segregation of people with a disability is not only still present but rampant. The only substantive change I have observed in the last twenty years is the type of prejudice encountered is no longer the same. The violation of disability rights is now couched in ever so polite and legal terms. Institutions know the ADA must be adhered to. Institutions know IDEA meetings must take place. This does not mean institutions want to follow the law or be inclusive. In my opinion, lip service is paid to the law. ADA violations are common place and twenty years post ADA stock replies, excuses, abound. Of course we are committed to being inclusive. Oh how many times I have heard that line used as I was excluded from participating in multiple activities at my son's public school when he was a boy. For instance, one year in elementary school the teacher sent home a note stating she was desperate for parents to go on a filed trip as chaperones. I filled out the form and wrote I would be happy to help. The next day I got a note "You cannot be included but thanks any way". Deeply annoyed, I asked exactly why I was excluded. Another note came home: "Chaperones must be healthy and there is no accessible bus". So much for the ADA. This pattern of exclusion never wavered in my son's public school. Public school administrators hated me and I will confess the sentiment was shared on my part. Inclusion from their point of view was costly and not necessary. I was not advocating for people with a disability but for myself alone. I was perceived to be singularly unusual and selfish in the extreme, a drain on limited resources better spent on students--average students, meaning students without a disability. There was a fundamental miscommunication that was never resolved. The school was, and to the best of my knowledge, remains hostile to the inclusion of parents with a disability.

Given the above, why was I shocked by the image? The exclusion is so stark and so obviously wrong no excuse is possible. This sort of segregation is over the top. It is blatant and makes me shudder. I shudder because it was public. We anthropologists would consider this a humiliation ritual. The group, meaning the audience and participants, do not value the person sitting in the wheelchair. Every man woman and child in attendance learned one thing at this event. Segregation of all people that use a wheelchair is socially acceptable. It is the norm. Inclusion is an ideal we can choose to talk about but it is not really something that is valued or readily achieved. Inclusion is something we get to pick and choose out of the goodness of our heart. Surely I am being too harsh, too demanding, too uppity. All words I have heard levied at me again and again. No, words cannot express my outrage. And like my son's public school, the school this child attends does not get it. Once the above image went viral the school released an apology of sorts. The school in question press release stated:

"It was a regrettable oversight that the student with special needs was not positioned with the rest of his schoolmates during the choral performance. The student has been a member of the chorus for the entire school year and there have been no prior issues. The choral director has cited several reasons why this occurred but accepts responsibility. The matter will be investigated and, if necessary, appropriate personnel action will be taken. That action could include a letter of reprimand and/or sensitivity training."

A regrettable oversight? Reprimand and/or sensitivity training? No excuse can explain away the the public humiliation this child endured. A humiliation sanctioned by the teacher, audience, and participants. No amount of sensitivity training is sufficient. No reprimand too lenient. Blatant bigotry reared its ugly head and the school did not even recognize it. This is as bad as the event itself. Worse yet, I suspect this is the tip of the veritable iceberg. I attended many public school events when my son was little. Children are repeatedly told to be on their best behavior. Notes are sent home about dress codes that cannot be violated. The reality is the teachers and school are putting on a show, a public demonstration celebrating how good the school is. Look at us, we are great. What I want to know is what happens to this student daily. Is he segregated during recess, gym, art class, on the school bus? Most likely. How many regrettable incidents take place when there are no cameras around? How often is he shunted aside during choir practice? Is what he experienced the norm?

The boy's mother said her son was inspired to sing in the choir because of the TV show Glee. I lowered my head in disbelief, deeply saddened. This boy's role model is a fictional television character played by a man without a disability. I again thought of my son's experience as a secondary school student.One day he brought home an assignment about civil rights. Great I thought. I told him to go to my office or the library and pick out a book that was of interest. Did he follow my suggestion? Of course not. He went on line instead and somehow stumbled upon the name Ed Roberts. I was thrilled. He filled out the terrible rubric secondary schools rely upon with a short paragraph about Ed Roberts life and fight for disability rights. The next day the rubric was returned with a short note "The assignment is supposed to be about civil rights. Disability is not an appropriate topic, it is different than real civil rights". And here lies the heart of the problem. There is no social mandate for disability rights. Sure a multitude of laws exist. Laws that are violated daily. Laws that are not valued. Laws that are mocked. Laws that are not even perceived as civil rights legislation. This makes my blood boil. What gets me the most angry are secondary schools that explicitly teach students and adults the segregation of people with a disability is not only acceptable but the norm, mere oversights easily negated by sensitivity training. At no point do students learn about disability rights as civil rights. Until this becomes part of the core curriculum in secondary schools and on college campuses I do not envision change taking place any time soon.

Disability and the Cultural Perception of Technology

Wheelchairs are n0t cool. Wheelchair use carries no social prestige. Wheelchairs are firmly associated with old age, paralysis and disability. I suspect people with no experience with disability think of two polar opposites in regard to wheelchair use. An elderly and frail person or a young paralyzed male in a sporty wheelchair. These are two stereotypes on opposite sides of the spectrum that are created with no foundation in fact. No thought, none, is given to the technology involved in making a rugged dependable wheelchair. No one that sees me thinks wow, that is one well designed wheelchair. I find this remarkable in that I have witnessed extended discussion about bikes, skis, cars, and electronics of every type. Not once has a person ever engaged me in a discussion of wheelchair design. I find this odd. Since the first rigid frame wheelchairs were invented in the 1980s wheelchair technology has borrowed liberally from the motorcycle and bicycle design. Wheelchairs, bikes and motorcycles have much in common. Spokes, wheels, brakes, tires, powder coated parts, gripping mechanisms to mention but a few obvious shared components. In spite of the similarity wheelchair use continues to carry significant social stigma. Nothing positive is associated with wheelchair use. One simply does not associate wheelchair use with fitness, mobility, and ability.

My views about wheelchair use are radically different. I love my wheelchair. Really, I do. I have not named my wheelchair as some paralyzed people do. Simi Linton, a noted disability studies scholar, for instance refers to her cherry red wheelchair as Rufus. When I see a person using a wheelchair go by my eyes go immediately from their face to their wheelchair frame. I want to to see dirt. I want to see scratches, slightly bent spokes, worn tires, and faded upholstery. I want to see signs of hard use. Spotless wheelchairs worry me. Does this person in a spotlessly clean wheelchair ever go outside? I also look at the wheelchair frame and fit. An active paralyzed person sits upright and is correctly seated. I then look at the wheels--very small front wheels are most common. I hate these small wheels. I know they are practical in an urban environment. Next, I look at the rear wheels and rims. No matter how well rear wheel rims are powder coated they take a beating. Well worn rims are a sign of hard use. Like bike wheels, rear wheels on a manual wheelchair have been revolutionized by technology. Good rear wheels stick out like a sore thumb. In short when I see a wheelchair I think action. I think work. I think does that wheelchair empower the person using it. All this goes through my mind in a flash.

Wheelchair technology has in my estimation stalled and has been stalled for more than a decade. Wheelchair design was revolutionized in the 1980s. For the first time since the 1930s wheelchair design advanced by leaps and bounds for a brief period of time. Many new companies were formed and much to my delight Everest and Jennings went out of business. Somewhere along the line wheelchair manufacturing became a big business. The innovative small companies that popped up in the early 1980s were bought out by large corporations or simply put out of business. Fewer and fewer companies manufacture wheelchairs. Giant companies such as Quickie have a monopoly on the market. Very few people like me exist in that I opted out long ago. I refuse to deal with any wheelchair company. I farm out any work my wheelchair needs to local small businesses. They treat me with respect and are happy to have my business. Not only have I saved a small fortune but the people that work on my wheelchair think it is cool. They get the technology. They get why my wheelchair cannot break. They get why all parts are internal. Every single nut or bolt has a reason to be on my wheelchair. The welds on the frame are elegant. The sealed hubs are top of the line. My wheelchair is simple in the extreme. I love how it looks--dirt and all.

The lack of respect wheelchair use and technology receives makes me crazy. Why can others not see what I see? I see a wheelchair and think there goes a person that has adapted. I think we people that use wheelchairs are a testament to the way we humans have adapted since we have been bipedal. I find such individuals endlessly fascinating. I also wonder when if ever we will be respected? I doubt that will happen in my life time but one never knows. And when discouraged I think of how we Americans love technology. Maybe, just maybe, some day people will see what I see. This is already taking place in the prosthetic industry. People like Hugh Herr and Aimee Mullins are constantly in the news. I read about how we are on the cusp of creating artificial limbs that are without question superior to our biological limbs. This amazes me. Yes, the technology is cutting edge but it is the social response that has amazed me. When kids and adults see prostheses they do not think tragedy or disability they think cool. People that know nothing about disability are drawn to prostheses. I just read an article at CNN.com that waxed poetic about protheses. Scott Summit who designs coverings for prosthetic limbs wrote:

"I feel that any product that is medical or corrective becomes a necessary augment to the body, and therefore, should live up to that role. It should respect the user, and offer to them all the quality of living and self esteem that it is able. Its success should be measured in terms beyond merely the pragmatic, but should aim to enhance the user’s quality of living in every way possible."

I hope I live to see the day when someone comes up to me and asks me a question no one ever has: How does your wheelchair enhance your quality of life? For that is exactly what it has done--at minimum. My wheelchair makes my life go. No wheelchair, no life. Crawling simply does not work. My wheelchair is a great gift, truly empowering technology. I cannot imagine life without it nor do I want to.

Huffington Post and Bungie Jumping

The Huffington Post under the section "good news" has a story entitled "Paraplegic Woman Goes Bungie Jumping". The video above is evidence that yes indeed "paraplegics" can bungie jump. The article begins "Thrill seeking doesn't stop when you lose the use of your legs". This is news? Why would being unable to use your legs stop one from seeking thrills? Paralysis may limit one's mobility but that is easily negated by a wheelchair. Has the Huffington Post never heard of adaptive sports or the paraolympics? And more to the point why was the woman, the human being sitting in her wheelchair, never identified by name. She is "paraplegic woman". Excuse me but this is about as dehumanizing as you can get.

I will admit I never heard of a person bungie jumping from one's wheelchair. The group that made this possible is Canadian group 9Lives Adventures. Sign me up! I would love to do this. I can only imagine the adrenaline rush. And the leap in faith! Wow, over the edge you go, total trust in your gear. This is worth looking into!

Dueling Editorials: Singer Versus Smith and Scary Revelations

Today the Guardian followed up its story about the so called Ashley treatment with not one but two editorials. First up was Peter Singer who predictably was supportive of the Ashley Treatment. The second editorial was written by SE Smith whose work I am unfamiliar with. She was staunchly opposed to the Ashley treatment. I urge people to read both editorials.

Singer's views have not changed since he came out in favor of the Ashley treatment in 2007. In his editorial no new ground is broken. I find both editorial distressing--the tone harkens back to 2007 when news of the Ashley Treatment spread across the internet and went viral. Back then there were two schools of thought--those for and those against. Both hurled vitriol at one another. And to be blunt, I had a hand in this. At the time, I was stunned and threatened by the story and the actions taken by a reputable hospital. It took years for a more civil discussion to emerge. Here I refer to the Seattle Working Group that published a consensus piece in the Hastings Center Report. Clearly the effort to find common ground has utterly failed if today's editorials are any indication of the way people are thinking. I find this distresing but not half as chilling as another story published by the Guardian today. Here I refer to "The Ashley Treatment: Eric's Story" by Karen McVeigh. I worry the shocking revelations in this story will be lost as the pointed editorials will get all the attention.

What shocked me in "The Ashley Treatment: Eric's story?" Not the over the top effort to pull at readers heart strings. When it comes to disability this is an old well worn theme. I have grown accustom to misleading and offensive comments such as "Erica has a normal life expectancy. But her body will never grow to adult size. The treatment, which included a hysterectomy to arrest the onset of puberty, has ensured she will remain – physically – a child forever." Eric is a child like Ashley--a person with a profound cognitive and physical disability who was subjected to the same therapy. Erica's parents were advised by Ashley's parents who encouraged them to be tenacious and insistent. Erica's parents believed that the Ashley Treatment was the perfect solution for their pillow angel. In 2007 they found a physician willing to help. In 2007 Erica had a hysterectomy and breast buds removed. After surgery she was then given high doses of estrogen that attenuated her growth. According to Erica's mother "The hysterectomy was the one bit I really wanted to do. We were adamant that she didn't deserve to deal with a period all her life, because of the pain and the hormonal changes. She is not verbal and can't tell us what hurts." All this is not new regardless of whether one is for or against the procedures. This is what took me aback. I quote:

"When they approached the gynaecologist for a hysterectomy, Erica's parents asked if they had to apply for a court order, but were told they didn't need one.
"Nobody questioned it," said EM. "The gynaecologist said: 'I'll do it. When do you want to do it?' We were surprised it went as smoothly as it did. We thought the insurance company would call but they didn't. My son asked whether we needed a court order. She said 'Oh, of course not, you want what's best for your daughter'."

Erica's mother went on to state:

"Before the hormone treatment began, Erica's parents had to go before the university's ethics committee. They took Erica along with them.
They told us they would like to develop a protocol for this. There was a panel of four. We said we know she's not going to get better. We want to keep her home and give her what she needs. I remember my husband saying one day she might have to have a male caregiver and how much more vulnerable she was going to be.
It's hard to talk about it, but things happen and at least if anything happened there would not be a pregnancy. It would give her much more dignity. We said it's not for all disabled children, I remember them sitting back and smiling and saying: 'This is right for your daughter.' One of them said how much her smile said about her."

Nobody questioned a child having a hysterectomy. The parental request went smoothly. Insurance covered it without balking. This reinforces what I have been hearing for the last few years from physicians, ethicists, lawyers and disability rights activists: the so called Ashley Treatment is quietly being done. No ethics review. No legal review. No follow up research. No long range studies. Nothing. This scares me to death. How can this happen? To me the answer is simple as it is dangerous. Children with profound cognitive and physical disabilities are not fully human. They do not share same rights as children that can think and move within a broad spectrum we deem normal. These children have no bodily integrity--their bodies can be changed at the whim of parents and physicians. These children do not warrant legal protection.

Erica's parents did not need to leave the United States to have the procedures done. They were performed at the University of Minnesota. If what Erica's mother said is correct the university is trying to develop a "protocol" for the Ashley treatment. This is news to me. The justification provided by Erica's mother dismisses any argument disability rights activists, scholars and ethicists have put forth noting: "People don't understand that we are talking about a small percentage – just one percent of the disabled population with disabilities like Erica's – who would be candidates for this treatment. It's not for everyone. There are grey areas."

Where did Erica's mother get the figure of 1% from? Ashley's parents. The one percent figure does not make me feel any better. So it is okay to forever change the bodies of children with profound cognitive and physical disabilities but not the other 99% of children. What does this say about our cultural perception of disability--again it is as simple as it is complex. People with a disability are not fully human. They do not warrant the same protections as other children. By extension, I cannot help but wonder do adults with disabilities not warrant care? Are we too subject to a different set of rules, standards and civil rights? People like Singer will reply I am comparing two separate populations of people. Children like Ashley and Erica are part of the 1% and as such can be treated differently. No harm will come to me and other people with a disability because we can express ourselves and defend our rights. This argument falls flat for me. We may have spent the last 40 years enacting legislation to protect the rights of people with a disability but there is no social mandate for such laws. Given half a chance, schools, corporations, universities, hospitals and every institution I have ever come across will break the law whenever humanly possible. As my son once told me long ago "Dad, no one cares about people with a disability". For me, the Ashley Treatment demonstrates this sentiment my son recognized at the age of six. Academics call it ableism. I call it bigotry. And in America bigotry is alive and well.

The Ashley Treatment: AD in the Guardian

AD is an acronym for Ashley's dad. Yes, Ashley's dad is in the news. The Guardian has published not one but two articles about the Ashley Treatment. I suppose they did not get the memo that the Ashley Treatment is now referred to as growth attenuation. Regardless, for all those interested I urge you to read "Ashely Treatment on the Rise Amid Concerns from Disability Rights Groups" and "The Ashley Treatment: Her Life is as Good As We can Possibly Make it" published in the Guardian today.

Over the weekend I will deconstruct these articles, in particular the long email exchange with AD. This post is a tease of sorts. The Guardian will be publishing another story tomorrow with another parent that has her child subjected to the Ashley Treatment. I will however provide one short quote that indicates a great divide between those that see disability as a social malady and those that consider disability to be a medical condition. AD noted the following:

"The Ashley treatment has made her far more likely to be comfortable, healthy, and happy. Given the limitations imposed by her medical condition, her life is as good as we can possibly make it."

I have no doubt Ashley's parents lover their daughter very much. I am delighted they are providing her the very best care. However, I am taken aback by the constant medicalization of her disability. Phrases such as "given the limitations of her medical condition" are unfortunate at best. Ashley has a physical and cognitive disability, a far cry from what I think of when I hear the words medical condition. As near as I can tell, Ashley is medically stable and has been for many years. She takes only one medication. I find AD to be troublesome. I cannot begin to understand why he has rejected each and every argument presented by disability studies scholars and activists. I cannot understand why he appears to think Ashley is singularly unique. There are many parents with children similar to Ashley who would not consider growth attenuation. Why the family has utterly rejected a social model of disability and embraced a medical model is a mystery. Worse yet, AD reports what I have been hearing for the last few years. Growth attenuation has gone underground. It is quietly being performed all over the country and abroad.

That's it for now. My first teaser post. Stay tuned for more.