Rational Rationing 3

angry doc actually wrote this entry shortly after the previous one in the series, anticipating that his readers will ask how he plans to incorporate the idea of fairness in deciding how we distribute healthcare resources.

Let's look at the issue of individual responsibility for a start, specifically at smoking.

angry doc believes we can make a case for discriminating against smokers when it comes to distributing healthcare resources on the grounds that:

1. There is a known cause-and-effect relationship between smoking and diseases

We know that smoking causes a number of diseases including heart disease, strokes, chronic obstructive pulmonary disease, and lung cancer.

2. The choice to start and continue smoking is an individual one

We recognise that by imposing a minimum age for smoking, and while we actively try to persuade people from smoking by use of graphic warning on cigarette packaging and health education campaigns, we have not banned smoking outright. In addition, smoking is not an essential need.

Now in the context of a pooled risk system, angry doc thinks he is justified in proposing that those who willingly subject themselves to additional risk should contribute more to the pool.

How to implement this then?

First, we need to identify a list of 'gazetted diseases' for which a definite cause-and-effect relationship with smoking is proven.

Once we have done so, we can move on to the next step: define how smokers should 'contribute more to the pool'.

Currently we have a few tiers in our subsidised healthcare system: in the outpatient setting we have three rates for citizens, permanent residents, and foreigners (at 'full-', 'half-', and 'none-' subsidised rates, which in terms of consultation translates to about $8, $12, and $16 respectively), and in the inpatient setting we have three subsidised rates ('C-", 'B2-', and 'B1-" classes, which translates to 80%, 65%, and 20% subsidy of the total bill). For convenience, we will refer to the highest subsidy rate in each case as C, the next as B2, and the least as B1.

If we stick to the existing system, we can stipulate that non-smokers are eligible for C rate.

For smokers, we can stipulate that they are only entitled to B2 or higher rate for the first outpatient visit or hospitalisation once the diagnosis of a gazetted disease is made.

For subsequent visits or hospitalisaion, patients who have stopped smoking (or have stopped smoking for a specified duration) are still entitled to B2 or higher rate, but those who are still smoking will only be eligible for B1 or higher rate.

No smoker is denied healthcare, nor is there any discrimination in the treatment he receives.

Now the difficult part: how do we identify smokers?

Given the disincentive of being a smoker, it can be assumed that smokers will not be forthcoming or honest when asked about their smoking status. A more legalistic approach is required.

We can stipulate that all citizens and permanent residents (since foreigners are not entitled to healthcare subsidy) who wish to purchase cigarettes (or tobacco products) be required to make a once-off statutory declaration that he has been informed of the consequences of smoking (both medical and the proposed legal ones) and that he intends to start smoking and bear personal responsibilities for doing so.

Subsequently a smoker will need to produce a photo-ID each time he purchases cigarettes. Each purchase is logged.

A smoker can circumvent this system by getting someone else to buy cigarettes for him, but the person who does so will himself bear the consequences of being logged as a smoker. To prevent smokers from pooling their risk by having one 'designated smoker' buying for the rest, we may factor in the amount of cigarettes purchased over time into our consideration for subsidy (i.e. you can bear the risk for a friend by buying the cigarettes for him, but your co-payment rate will be higher if you are deemed a 'heavy smoker').

angry doc can already see some objections to this system:

1. It imposes a 'double jeopardy' on smokers, who already pay a duty for cigarettes

angry doc cannot deny that. Under the proposed system, a person is penalised for both his decision and the results of his own decision.

2. It infringes individual privacy and liberty

It infringes privacy, but not liberty. A smoker is still allowed to smoke if he accepts that he will receive less subsidy as a result of his decision.

pathdoc raises other questions:

"How many cigarettes a day for how long constitutes a smoker? How long must one stop smoking before he is considered a non-smoker? Is the smoker of a cigarette a day to be treated the same as one who smokes 100 a day? What about the type of cigarettes? Does the nicotine level matter? What about cigarette filters that claim to remove most of the tar?"

angry doc thinks those answers can be answered objectively by looking at data on smoking and pathogenesis. We may need to further grade the co-payment rate based on how much one smokes, but overall he thinks the policy is sound.

What do you think?