When the Supreme Court upheld the Affordable Care Act, relieved supporters happily looked forward to implementing the law over the next several years, while infuriated opponents vowed to repeal the law, even as some states refuse to implement its Medicaid and other provisions. Whatever happens to the ACA, the need to contain the costs of health care will not disappear, and indeed will almost certainly grow more pressing. The conflicting policy goals of ensuring that all Americans have access to “basic health care” while containing the system’s costs will roil bioethical and public-policy debates for many years to come.
And therein lies the rub. “Basic health care” as envisioned by the medical intelligentsia, government technocrats, and their media cheerleaders is neither basic nor necessarily health care. To an increasing degree, “basic” coverage often includes what I call “consumerist” procedures that, though delivered in medicinal or clinical contexts, are not actually medical in nature.
By “medical services” I mean the prevention, diagnosis, treatment, or palliation of injuries or illnesses. The term “consumerist” identifies procedures that use the traditional methods and tools of medicine—surgery, drugs, technology—not to treat actual maladies but to fulfill patients’ personal desires, enhance their chosen lifestyles, and assist them in attaining goals unrelated to their physical health.
Cosmetic procedures are the clearest examples of consumerist “medicine.” Botox treatments, facelifts, collagen injections, and surgical enlargement of healthy breasts clearly do not treat or detect pathologies. Instead, patients undergo these procedures for nonmedical reasons: to boost self-image, appear sexier, feel happier and more confident, or attract or please romantic partners.
Reproductive services are another field rife with consumerist medicine. A growing number of professional women freeze and store their eggs for future fertilization in case they do not find a suitable partner before their fertility diminishes. Some, reports Ronald Bailey in Reason, “are now taking advantage of ‘fertility insurance’ by having fertility clinics retrieve and freeze their eggs. . . . [The] women who decide to have their eggs frozen are not infertile. They are making an ‘elective’ or ‘social’ choice.”
Doctors are now testing ovary transplants as a means to stave off menopause. Many girls being born now will live several decades beyond menopause, and can extend their fertility by having parts of their ovaries removed and frozen when they are young and replaced incrementally every decade as they age. “That would mean women would not have to ‘watch their body clocks,’” noted a writer in the Daily Telegraph, “and would only be physically limited by their ability to carry a baby and give birth.”
The natural aging of our reproductive abilities is not a disease. It is not pathological but a normal part of life. Procedures such as freezing eggs or storing youthful ovaries to extend normal fecundity are not properly considered medical care. They’re consumerist procedures. In vitro fertilization (IVF) started as a medical procedure intended to help infertile married couples bear children. Now, it is a multi-billion dollar industry that often serves people who are perfectly capable of bearing or siring children, but who, for various reasons, prefer not to have them by natural means.
For example, a homosexual male couple paying an egg donor and a surrogate mother—now called a “gestational carrier” in dehumanizing industry parlance—to facilitate their becoming parents is making a consumerist choice, since being male is not a pathology. The same goes for a woman who undergoes IVF and hormonal therapy to give birth after menopause. This isn’t to say that these patients don’t highly value the consumerist services they seek. It is to say that they are not related to actual body dysfunctions or disease processes.
Other common examples of consumerist medicine are elective abortions that terminate healthy pregnancies; sterilization surgeries and contraception that aren’t required for health reasons; and the prescription of Viagra or similar drugs, when not needed to overcome symptoms of a disease or the side effect of a medical treatment that inhibits sexual function. (Whether facilitating the ability to have sexual intercourse should be considered basic health care is a legitimate but different question.)
There is no question that consumerist procedures are integral to the modern view of full-service health care. But that’s the point. Our recent policy debate is not about what constitutes full-service health care, but rather how to determine what should be considered basic coverage that the community has a responsibility to provide for its members.
Consumerist procedures have expanded steadily in recent years, absorbing increasing percentages of limited health resources and diverting professional expertise and infrastructure away from the truly medical needs, often on the collective dime. The Atlantic reported in January that Buffalo’s school system pays for teachers’ cosmetic surgeries—to the tune of $9 million in 2009. So many teachers have taken advantage of this consumerist entitlement that cosmetic surgeons advertise in the teachers union newsletter.
True, Buffalo’s situation is extreme, but the trend is clear. Recently, what is effectively the United Kingdom’s health-rationing board, the National Institute for Health and Clinical Excellence (NICE), recommended that the National Health Service (NHS), one of the U.K.’s publicly funded health care systems, pay for sophisticated artificial insemination procedures for lesbians and for IVF treatments for all women up to forty-two years old who have been unable to conceive.
Should society pay for artificial insemination when, because it lacks funds, it must ration some life-extending cancer treatments to the terminally ill, as sometimes happens in the U.K.? (Even if the society wants to promote homosexual equality by ensuring that lesbians can bear children without sexual intercourse, this is not precisely a medical concern.) Should the collective be financially responsible for expensive IVF procedures for women unable to conceive because they are at the end of their normal childbearing years when NHS hospitals and nursing homes are in the midst of a severe medical-resource crisis?
While the United States doesn’t have the same socialized system of “free” health care as the United Kingdom,that should not make us sanguine. The passage of the ACA has moved us toward the kind of medical centralization found there. Indeed many of the act’s primary proponents, such as former Senator Tom Daschle and the editors of the New England Journal of Medicine, yearn to establish an American version of NICE to centralize the control of health care governance and keep down costs. That would open the door for political decisions to mask guidance as health care, and for many constituencies, it would mean boosting consumerist coverage, even at the expense of the truly medical—hence the controversy over “death panels” that continues to swirl around the ACA.
This process has already begun. One of the "rst regulations promulgated under the ACA requires most employers to provide insurance coverage for free sterilization surgeries and contraception, with a very limited “house of worship” religious exemption that does not apply to most church agencies beyond the cloister.
That is just the first of what will likely become many consumerist coverage mandates. Does anyone doubt that the current leadership of the Department of Health and Human Services hopes to order health-insurance policies to cover elective abortion? Or that most IVF procedures will eventually be considered basic health care, as is already the case in the United Kingdom and Quebec?
And it won’t stop there. The city of San Francisco already covers sex change surgeries for its transsexual employees. Oregon’s Medicaid pays for physician-assisted suicide while explicitly rationing some life-extending medical interventions for its most seriously ill recipients.
To be sure, the distinction between medical and consumerist procedures is not always easy to discern. At what point do common complaints of aging, for example, become disease? And when does an expensive treatment for a bona fide medical problem, if undertaken for a life style enhancing reason, become consumerist? If a patient can walk well despite an arthritic knee but cannot play tennis, should a knee replacement be considered medical or consumerist? Moreover, nearly everyone supports the coverage of some procedures like restorative surgery after serious facial burns, even though, strictly speaking, restoring normal appearance does not treat a health-threatening condition.
But here’s the bottom line: Regardless of the ultimate fate of the ACA, as a society, we appear to have decided that guaranteeing access to basic health care is a collective obligation. If that accommodation is to have any chance of being affordable, we will have to draw proper boundaries between the basics that insurance should provide and the extras that people should pay for themselves, either through insurance riders or by paying the full price.
A good starting point in that difficult and complicated process would be to exclude obvious consumerist services—starting with those we’ve discussed here—from the definition of basic health care. That would better preserve our collective resources for the most pressing and serious medical needs.
That won’t be the end of it, of course. We will also have to delineate which medical services are basic and which extras. But that is a discussion for another day.