The Texas Lieutenant Governor, Dan Patrick, was recently lambasted by much of the press for his comments in an interview he did on the Fox network. He said that he is 69 years old and he was willing to take the chance that he could be infected from the COVID-19 virus and die from it in order to protect the economy from public health measures such as shutting down non-essential businesses. New York’s governor Cuomo responded that his elderly parents did not agree.
Let’s remember that Lt. Gov. Patrick was a radio and television talk show host before he was elected. It’s just in his nature to speak in dramatic terms.
But what Lt. Gov. Patrick said actually represents a difficult truth. We have a choice in this country of how we react to COVID-19 and how that choice impacts the economy. Unfortunately, we must talk about lives and dollars in the same sentence.
I read an economic study recently where economists modeled different projections of the spread of COVID-19 and how it would affect the economy. It was a commissioned study that I was asked to review from another state, so I can’t share the details. The gist of the study was that if the virus was allowed to spread rapidly there would be hundreds of thousands of deaths quickly, maybe up to 2 million, but the hit on the economy would be brief and short lived. If we flatten the curve, and as I’m sure everybody has heard that concept a dozen times by now, then the deaths are minimized but the recession is deep and wide.
What is the total hit to the U.S. economy of the COVID-19 pandemic? All the reports I reviewed estimated a GDP contraction of about 3%-6% for 2-3 years. A report from KPMG estimated the Federal Reserve will add about $6 trillion to its balance sheet, so let’s go with that number for now.
What are they doing in other developed countries? Italy and Spain were hit early and hard. They did not have much time or capacity to think about much of anything other than just trying to cope with the crisis. As hospitals become overwhelmed in Italy, ICU doctors there disconnected patients on ventilators who had been on the machines for a few days, but were getting worse. Presumably, they used some judgements about which patients to leave on a few more days based on factors such as age and comorbidities. Their justification was that other patients were deteriorating and needed the vents also, but were more likely to survive.
In Britain, Prime Minister Boris Johnson has sounded a little more American than usual, before he went to the ICU at least, talking about expanding ventilator capacity and saving lives, without much suggestion of accepting limits or acknowledging scarce resources.
Worldwide, even in countries with the most advanced ICU technologies, it looks like the death rate for people who become so sick with COVID-19 they require mechanical ventilation is about 50%. And if the worst of the surge is about to happen in a few weeks, then all of the efforts of non-traditional vent companies to make new vents will mostly be too little/too late, as it usually takes 2-3 years to invent, test, and approve a new vent model. Even with many regulations and expectations of testing eased, the surge of vents won’t likely materialize until the summer, well past the worst of the surge of cases.
So what is the cost per year of life saved with the choices we have made in the US? This is a very difficult number to even estimate, because there are still so many unknowns. Let’s assume the total hit to the U.S. economy is $6 trillion. For this money, let’s assume that the curve is flattened and one million lives are extended because they didn’t catch COVID and die. This means that it costs roughly $6 million to extend a life.
80% of people dying from COVID-19 are greater than 65 years, and most of those are older than 80. Let’s assume the average age of death is 75. The average life expectancy of a 75-year old in the U.S. is about 10 years. Therefore we are spending about $600,000 per year of life saved.
There was an article that was published in 1986 that coined the term “rule of rescue.” In a nutshell, the paper observed that people are more willing to spend money on a visible death then an invisible or seemingly random death. For example, people are more likely to support a very expensive chemotherapy for cancer that would not extend a life very much over public health measures that would extend a lot more years of life at a lower average cost per year. This principle is clearly playing out in this pandemic. The ethical question is whether it is defensible that the recognized life extended has more value than the hidden life. Most would say no, but acknowledge the difficult psychology of the situation.
Let me say, as I always do in situations where we must talk about difficult tradeoffs, that the cut-off point of where to spend money and where to say “we simply can’t afford it,” is not my place nor any other physicians.
But other developed countries are willing to make these difficult trade-off decisions. As a recent example, the UK National Health Service (NHS) refused to pay for advanced cystic fibrosis drugs, because the manufacturer, Vertex, charged too much (per NHS/NICE guidelines). After over 18 months of negotiation, Vertex agreed to lower its price and gave other concessions. Of course the actual price is shrouded in secrecy, but commentators estimate that the NHS will spend a little more than £10,000 (about $12,500 U.S.) per year for these drugs, compared to about $258,000 per year in the U.S. (This estimate might be a little high because of the all of the PBM rebate games). Undoubtedly over that 18 months, people in the UK with cystic fibrosis died who might have lived longer if they had access to the improved treatment. But the NHS refused to buy the drug that was too expensive, because it has a budget and has to live within certain limits to preserve resources for other aspects of the economy.
And what does this increase of the Federal Reserve’s balance sheet really mean? This is more debt that will be placed squarely on the shoulders of our children and grandchildren. Once the economy gets back on its feet will we raise taxes on ourselves to payback the massive loan to ourselves? That’s laughable.
The tiny glimmer of hope Lt. Gov. Patrick’s comments can give us, is that he showed it is actually possible for a U.S. politician to talk about lives and dollars of economic impact in the same sentence. When this pandemic finally plays itself out, which I suspect will actually take several years with several recurrent surges, I hope that this brief display of courage to face facts, state transparency of thought, and demonstrate an eyes-open understanding of difficult tradeoffs in health and economic choices, means that we might actually have some of these difficult conversations in the future without completely emotionally melting down.
A boy can dream.
Great piece. thanks
I appear to be unable to send email to admin@healthscareonline.com from either my utsystem or my fastmail address – it’s undeliverable . . . you’ll want to delete this from the blog but didn’t know a different way to communicate with you as I’m not sure how to find your phone though I had it at one time.