Eye on the News

Nicole Gelinas
Who Pays?
From breast implants to diabetes, Western health care is a mess.
3 February 2012

What do a breast-implant scandal in Europe and the latest news about Paula Deen, the Southern-fried American chef, have in common? Both demonstrate, in their own ways, what’s wrong with Western health care. The free market alone can’t fix health care—but neither can the government. Instead, government must play a limited role and stick to it, allowing the market to work. That’s not happening today.

In Europe, tens of thousands of women have learned that they received industrial-grade silicon—the kind used in mattress filling—for their breast implants. As Britain’s Daily Mail reports, Frenchman Jean-Claude Mas, a butcher’s son, launched his breast-implant business, Poly Implant Prothèse (PIP), in 1991, selling the silicone sacs to clinics around France, Britain, and Latin America. To cut costs, he allegedly switched from medical to mattress filler, and skimped on a protective sheath. The result: the implants are rupturing much more frequently and faster than normal—causing pain, deformity, and anxiety. As Gemma Garrett, a former Miss Great Britain who paid to have her implants removed, told the newspaper, “it’s painful and unpleasant. . . . I am also very scared.”

Who’s responsible—and who pays the $233 million it would cost to remove up to 45,000 British women’s implants? Mas, of course, is the chief culprit. His business has been shut down. Last week, French police arrested him on suspicion of “unintentional harming.” More charges could follow. The rest of the trail of responsibility is straight as well. Breast implants, as an elective procedure, lie squarely in health care’s free-market province. Most of the 45,000 British women who got the implants did so for cosmetic reasons at private clinics. The clinics bought Mas’s product because it was cheap—too cheap. The victims’ recourse lies with these clinics, whose owners could, in turn, sue Mas to defray their own costs.

At first glance, recourse seems relatively straightforward, even though one in ten plastic-surgery clinics fails each year, meaning many women have no place to “return” their defective product. These women took a medical (and financial) risk in pursuit of a better appearance. Businesses fail. Existing clinics are concerned that they, too, will go out of business if they have to perform free surgeries to remove the implants they put in. Yet as the Mail editorializes, if companies “have given their clients a product which is unsafe, they—not the hard-pressed UK taxpayer—should ultimately foot [the] bill.”

Yet the bill may well fall into taxpayers’ laps. Britain’s National Health Service has said that it will pay to remove implants that women got after breast-cancer surgery. That sounds reasonable enough. But the French government has already said that it will pay to remove all victims’ implants, putting pressure on Britain to do the same. Britain is under fire, too, because implants are regulated medical devices in the U.K. As the Mail also notes, Britain’s Medicines and Healthcare Products Regulatory Agency (similar to the FDA in the U.S.), which approved the implants, may have ignored surgeons’ warnings. The government may want to pay up now to avoid scrutiny of its watchdog’s decision-making.

The NHS may pay for another reason: its medical experts could determine that doing so would avoid higher government costs later, as women suffer the ill effects of silicone seepage and come in for government-paid care. The NHS knows that it’s likely to do a better job treating these women than would a clinic whose managers view them as people they will never see again. Indeed, national health officials have said that the government might pay for implant removal if women show a “clinical need,” a standard they didn’t define.

Judging by the comments on U.K. websites, many Britons object to the idea of the NHS paying for breast-implant removal. A woman with money to buy breast implants, they figure, can surely afford to get them removed. But as the health-care industry changes, expect more of the same questions about who should pay. More and more “health care”— from bionic knees to back surgeries—is purchased not to alleviate acute pain or sickness but to improve “quality of life.” Is a middle-aged man requiring intensive surgeries so that he can keep jogging any less vain than a mother of four who wants perky breasts?

Furthermore, in America, the health-care industry has for more than a decade treated drug patients, at least, as consumers. Drug makers market expensive products to the public, not to doctors. Consumers want what they think is best, even if it’s expensive. It gets more complicated when you remember that more people go abroad for cheaper surgeries or for experimental care that they can’t get stateside. When something goes wrong with these “personal choices,” everyone else back home has to pay to fix it, whether through private or government insurance.

As health-care costs rise, Americans will wonder: why should I pay, either through higher private-insurance premiums or through tax dollars, for you to take the latest blockbuster cholesterol drug, when you don’t have to pay for my glass of wine? The Catholic Church is rightly outraged at President Obama’s insistence that it pay for workers’ birth control. But a population-control fanatic might be equally outraged that he has to pay to deliver someone else’s baby.

To judge from the reaction to Paula Deen’s latest news, people are already asking these questions. Two weeks ago, Deen, the celebrity chef, went on the Today show to announce that she was suffering from type 2 diabetes. To much criticism, she’s become a pitchperson for a $500-a-month diabetes drug, Nova Nordisk’s Victoza. Fellow chef Anthony Bourdain, noting Deen’s unhealthy cooking, said that he was “thinking of getting into the leg-breaking business, so I can profitably sell crutches.” Steve Cuozzo, the New York Post food critic, who also has diabetes, asked Deen in a column: “Before using a ridiculously expensive medication . . . did you try other cheaper, highly effective drugs—like metformin, which . . . costs less than $20 a month?” Driving much of the outrage is the fact that Victoza is covered under President Bush’s prescription-drug expansion of Medicare—meaning taxpayers have the pleasure of subsidizing Deen’s perceived excesses.

One partial solution to this burgeoning dilemma is for the government to require all but the destitute to pay for their day-to-day health care. Insurance, private or public, would pay only for catastrophic costs. Part of government’s job would be to regulate the health-care market competently. When government errs in this job, taxpayers would have recourse to the voting booth—not to the public purse. Government’s other job would be to maintain a free market for health care. Doctors and hospitals would have to post prices on public websites for everything they offer, and they wouldn’t be able to discriminate opaquely on price among patients, as they do now. If people want to consume health care, they should act like consumers and pay for what they buy.

But voters aren’t likely to react well to the proposition that, if they can afford cable TV, they can afford diabetes medication. People like the idea of someone else paying for full-body scans and sleeping pills. And not everyone will agree on what constitutes a catastrophic cost: where a healthy young woman may have an extra $300 a month to save, another young woman with a preexisting condition must spend that money on medication. Is that fair?

Absent honest political discussion and realistic expectations, we’re likely to live in a world where public and private health-care systems continue to intersect in dysfunctional ways. Care providers will “compete” on how to game the system, rather than on delivering better health care at less cost.

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