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AVe are rapidly sailing into a new and morally painful world of American medicine. The central characteristic of this new world is that we have invented more medicine than we can afford to pay for. Even if we could successfully remove all the inefficiencies from the American medical system, we are still confronted by a new painful reality: infinite medical needs have run into finite resources. This should not really surprise us. One of the universal historical truths is that resources are limited relative to wants. But it still comes as a painful realization. Americans are really good at avoiding reality. We pretend that we don't ration medicine yet thirty-seven million Americans are not covered by health insurance and the Robert Wood johnson Foundation has found in a recent year that a million American families had one or more members who were denied access to health care. it is said that maturity is a recognition of one's limitations." I suggest that maturity in American society involves recognizing our limitations and moving realistically to set priorities in all aspects of American life, particularly health care. What yardsticks should we use when we prioritize medicine? Thoughtful people who have wrestled with this question suggest there are generally two standards: (1) improving the length of people's lives, and (2) improving the quality of people's lives. Setting medical priorities is a multilateral equation. These decisions will not only be morally painful but immensely difficult as we compare one beneficial procedure with another beneficial procedure. The agony of choice can be seen in the recent decisions by Oregon and Virginia not to pay for soft tissue transplants but, instead, to spend the money on prenatal care and basic health care for the medically indigent. While politically difficult, most thoughtful people recognize that it is better to cover basic health care for the many rather than high technology medicine for the few. As George Annas has warned us, "we have been doing more and more to fewer and fewer people at higher and higher cost for less and less benefit." Yet as difficult as the transplant/basic health care tradeoff is, it is easier than most that lie in our future.

TO prioritize American health care spending we have to ask basic questions: "How do we buy the most health care for the most people?" "In a world of limited resources, what procedures are the most cost effective?" is very unlikely to meet these tests. In a nation that doesn't cover basic health care for all of its citizens, doesn't vaccinate all of its children, doesn't provide prenatal care to all of its women, it is very unlikely that public policy can justify paying approximately $8,000 a year a person for a drug that does not cure but only alleviates symptoms. This is not a moral judgment, but instead a judgment of health policy. We wish abstractly that we could do everything for everybody but if we can't and if we must set priorities, there are many, many medical procedures that we now deny people that will have a higher priority than AZT. AZT does improve the quality of people's lives but the disease is terminal. Until we cover basic health care for pregnant women and indigent children, it is unlikely to make many people's priority list.

As in most states there is a strong movement in Colorado to get state government to pay for AZT. Much of the political discourse is out of the 1960s, as those who object to AZT as a medical priority are painted as uncaring" or conservative." So many of our memories and political institutions were built in the 1960s when America doubled its wealth every thirty years arid we thought we could do everything. The reality of the times in which we live is that we can't do everything. Being in government today is like sleeping with a blanket that is toO short. We simply cannot cover everything. We must make choices, however painful.

Excluding AZT from a list of priorities is not a matter of not caring, but of understanding that the "opportunity costs" of those dollars are much higher elsewhere in the system. When we let go of the illusion that we can pay for everything and start to set priorities, too many other health procedures will have higher claims on our limited dollars. The debate over AZT thus becomes a harbinger of many similar decisions that we are going to have to make in the future. Those people who argue that limited dollars can be put to a higher use than AZT should not yield one inch of moral ground. We care just as much as the advocates of AZT; we are just demanding that limited dollars be expended in a way that will bring the highest amount of well being to the maximum number of our citizens.
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Title Annotation:Who pays for AZT? case study
Author:Lamm, Richard D.
Publication:The Hastings Center Report
Date:Sep 1, 1989
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