There has been a maelstrom of news and opinion recently about the revised guidelines for mammograms and pap smears. On the one hand, it is either abysmal or fortuitous timing for these recommendations to emerge during a national debate on healthcare reform legislation. This is playing right into the hands of those who would have you irrationally believe the government is trying to ration your care in an effort to kill you. The reality is that timing aside, these recommendations and other scientifically based statistical studies are released all the time. And not just the government, but the insurance companies who already effectively control your access to healthcare make coverage decisions based on such studies.

The real issue here is the recommendations shine a glaring bright light on the reality that any insurance based healthcare plan balances the needs of the many against the needs of the few. This is not specific to government run vs. privately run plans. This is the reality that no group plan can afford to give everyone every last bit of diagnosis or care they might desire at a price we can collectively afford.

This is easy to understand at an impersonal level. It would be a waste of money to test everyone who came to the doctor with a cough for tuberculosis. The cough is weighed with other symptoms, including the clinical as well as the statistical likelihood the person could have been exposed. The reality is that this process misses a small percentage of cases that could have been caught early if everyone were tested at first phlegm. But the cost, anxiety, false positive rate, and inconvenience of all that testing is balanced against the actual number of cases slipping through the cracks. It’s impossible to seal all the cracks of all the diseases and conditions. Every doctor, every insurance company, every hospital, makes a cost benefit decision to determine the point of diminishing returns. They do this in full recognition that they are statistically condemning some small number of people to being undiagnosed.

This all makes sense at the dispassionate level of statistics. Any group health plan needs to draw the lines somewhere. Everyone cannot be entitled to unlimited care. But at the personal level, I want my family, my friends, my loved ones, even my-self to have access to the best of everything. If I could have my way, we’d all have one of those two-minute Star Trek medical scans every week to check for every known condition in the Star Fleet data bank, regardless of the cost to the insurance company. But in practice, if such a scan existed, and I was paying out of my pocket, and the scans cost $5000 each, would my kids get one every week? Every month? Every year? Just to be sure? Probably not.

All this puts me in a difficult position. I do understand the trade-offs, the statistics, and the economics of the situation. However, I have personally benefited from some aggressive, probably not statistically justified medical diagnostics. A few years ago, I went to the doctor for something unrelated and just mentioned in passing that I had an odd ringing in one ear. She knew it was probably nothing, but sent me to a specialist anyway. He concurred, but just to be sure, he sent me for an MRI because some insignificant portion of 1% of people with that symptom have a small brain tumor. They found and removed my tumor a few months later.

To be honest, had I been paying out of pocket and they had asked to run $5000 worth of tests to diagnose a ringing ear, just to be sure, I’d have probably said no thanks. If I had to appeal to an insurance company to cover the tests, I’d have probably acquiesced to the math and waited until my symptoms worsened. This would have resulted in treatment delays, a much worse prognosis, and I wouldn’t have the quality of life that I enjoy today. But it’s probably how it should have panned out.

The cruel reality is that all healthcare is about economics. Someone has to bear the cost of your care. Whether that cost is borne out of your pocket, your paycheck, or your taxes, it’s still a question of how much we can afford. There simply is a point where the cost is too high. The implication of that ceiling is that no matter where we put it, some small number of people will wind up sicker than they would have been if we’d pushed the ceiling a little higher. And we’re all okay with that as long as those “few people” are strangers in a statistical database.

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