LET'S face it: I could do with a good face lift, but it's not covered by my insurance. I can't afford it, so I tell myself the lines show character, and I make peace with my mirror. That's life: Some things are just too expensive, I say, and push the matter out of my mind.
Would I feel the same if I needed a heart transplant, a pacemaker or an expensive heart-regulating drug?
I doubt it. Yet that may be the kind of decision someone will make for me down the road. For the high cost of medical care in this country -- $659 billion spent on health care last year alone -- means that policy makers and insurers are discussing options they never would have dared before.
Since $100 billion of this expenditure was through the Medicare program, those most frequently targeted for drastic changes in our medical practices are people over 65. Forbidding them expensive procedures could be a financially efficient way to go. But for those of us who rely on insurance (both government and private) to pay the bulk of our health bill, the implications are very scary.
Radical, and frightening, proposals calling for health-care rationing come from Richard Lamb, former governor of Colorado, now at the University of Denver, who complains there is too much technology involved in caring for the elderly. Norman Daniels, a philosopher at Tufts University, proposes that health-care dollars should be concentrated at the beginning of the life span and spared at life's end. And ethicist Daniel Callahan of the Hastings Institute advocates denying expensive life-saving care to people who aren't a good societal bet, those in their late 70s and 80s. Some people are just too expensive.
Crying foul won't stop proposals on new ways to control rising health-care costs. There are kinder approaches, including a shifting emphasis to preventive care and reconsideration of a health delivery system to approximate what used to be called socialized medicine, possibly based on the Canadian model.
But whatever path this process takes, cost-cutting will remain the driving force. Now the government has proposed factoring cost into its equation as to what new procedures it will, or will not, allow under Medicare.
New Medicare rules would consider the cost of any new device, medical procedure or drug in deciding whether to approve its use. In the past, Medicare only checked for safety and effectiveness. The new plan would compare the price of new products to the cost of what's already on the market in deciding what the government will reimburse. A new high-tech scanner, for example, would not be permitted if existing imaging equipment could do the job at a lower cost, even if not as well. The proposal, if enacted, would quickly spread to the private sector, since private health insurers historically follow the government's lead.
Health policy expert Robert Binstock, author of the forthcoming book, "Too Old for Health Care?" praises the proposal and calls this "a welcome step in putting pressure on manufacturers of medical equipment and supplies to have some constraints in their pricing policies.
"I don't think it's unreasonable to compare new treatments on cost and efficacy with existing treatments. It might get the manufacturers and those who hold the patents to re-examine their pricing structure," says Binstock, political scientist and head of gerontology at Case Western Reserve University. For Binstock, such cost controls present a far more preferable approach than categorically denying care to certain segments of the population -- namely, the elderly.
Whether the nation chooses to spend money on health care rather than other things is, in Binstock's view, a political choice. Yet he points to "tremendous waste in marketing and profits in the health-care system" and questions why this industry should be permitted to rack up disproportionately high profits. Binstock figures profits on medical equipment, supplies and pharmaceuticals are between 40 percent to 50 percent, compared with 2 percent on food items. (Food is also a basic need.)
Medicare changes rarely come about without protest. Older people object to cost criteria in future decisions about their health care. Medical people warn that such thinking inhibits progress. And they are right. But something must be done to control health expenditures, and small corrections to the existing system now may help block major, frightening changes later on.
Economists, budget makers, ethicists, even families of the elderly whose loved ones live artificial half-lives in intensive care, are finding fault with the way things are. Someone is going to tinker with this system. There is too much dissatisfaction to assume that it won't happen soon.
Ghita Levine writes occasionally on the policies and issues surrounding older people.