Wednesday, March 21, 2012

Paying for Lifestyle Choices

Imagine a world where the public was only "on the hook" for the lowest cost, medically neccessary standard of care. That every Canadian was faced with the same challenge: to only access public health care that is medically neccessary, the lowest cost, and not the result of a "lifestyle choice" - and that the determination of these things was done retrospectively. That EVERYTHING else was paid for out-of-pocket or via private insurance.

Public health care costs would plummet. At the same time out-of-pocket expenses would sky rocket and the quality of life of many Canadians would suffer greatly.

The reality is that much of health care spending is the result of lifestyle decisions. The decision to smoke a pack or more of cigarettes a day. The decision to drink excessively. The decision to forego adequate amounts of exercise. The decision to eat inappropriately. The decision to have children in the first place. The decision to undergo surgical sterilization. The decision to partake in extreme sports. The decision not to wear a helmet. The decision not to adhere to the advice of your physician. The decision to undergo an abortion. The decision to do illicit drugs. Yet, the public health care system pays for these lifestyle decisions.

It is also true that most health care spending occurs in the final two years of life. A time when that spending has little impact on the quality or quantity of life that remains - arguably much of this spending is 'not medically neccessary' as it does little to improve the health status of the person receiving the service. The returns on this health spending tend to be be very marginal. Again, the public health care system pays for the heroic measures taken to stave off what in many cases is inevitable.

However, when it comes to treatment decisions for pregnancy - there is a vocal outcry of wasting health resources by allowing women to exercise legitimate decisions about how their children are delivered. There is a refrain "The public should not pay for THIS lifestyle choice." I should note that THIS lifestyle choice might prevent the need for reconstructive surgery later. THIS lifestyle choice might prevent a life-long disability. THIS lifestyle choice impacts on a woman's sense of self-determination. THIS lifestyle choice might prevent an emergency c-section. THIS lifestyle choice, and the availability of it very well might make the difference between a woman choosing to have ANY children or none at all. Yet, THIS lifestyle choice is somehow open to public opinion as to whether or not it should be paid for. THIS lifestyle choice is NOT on par with a tummy tuck - and is far less costly than the health impacts of many other publicly supported lifestyle decisions.

Is this because only women give birth and have to deal with consequences of doing so?

Health care sustainability and spending is a very real dilemma - however, looking to 'save healthcare' by restricting choice in maternity care (access to epidurals, c-sections and other interventions) is misguided at best. This is especially true in light of evidence that suggests that an elective c-section at term might be cost-competitive with a planned vaginal birth, particularly when all costs of planned vaginal birth (emergency c-sections, damage to the pelvic floor, severe birth traumas) are taken into account.

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