What is a disease? (II)
In my last post, I argued that we should settle Viagra coverage question by old fashioned cost/benefit analysis.
By cost/benefit analysis, I just mean that Viagra should be judged by the same criteria as any other drug jockeying for a spot on a public insurance formulary. The challenge is to create the best overall insurance package in a zero-sum game--every dollar we spend on Viagra means less money for something else.
We should be asking the same basic questions about every drug:
- How much does this treatment cost?
- How many people will benefit?
- What kind of benefit will they get: longer life, pain relief, better marriages...?
- How great is the benefit to the individual patient?
- How great is the benefit to society?
All I'm saying is that that we've got to survey the options, crunch the numbers, and see how much value Viagra delivers for the money. Cost/benefit analysis sounds cold and inflexible, but it isn't necessarily so. Private insurance companies only consider profit and loss, but a public health insurance scheme can take a much broader view of costs and benefits. Non-monetary benefits include effects on society at large, fairness, fulfillment of public preferences, etc.
Of course, we can't rank Viagra without assigning a value to sexual health. There are fundamental differences of opinion about the value of a healthy sex life. That said, much of the rhetoric about the dispensability of sex seems out of step with most people's priorities. (Not my brain, that's my second-favorite organ!)
At this point you're probably wondering, "Cost benefit analysis, as opposed to what?" As opposed to using an overarching mission statement or criterion like "Medicaid's mission is to prevent and treat disease."
If we use a criterion model and we want to know whether Medicaid should cover Viagra, we have to determine whether Viagra prevents or treats any diseases.
Clearly, Viagra is often prescribed to treat impotence that is a complication or a symptom a disease like diabetes or cancer. If our criterion allows for symptomatic treatment for pain and nausea, why shouldn't it extend to the symptomatic relief of erectile dysfunction?
Of course, real bone of contention, if you will, is whether health insurance should cover Viagra for men whose impotence can't be explained by any other medical condition. "Erectile dysfunction" (ED) and it's low-key cousin "erectile difficulty" are Pfizer's buzzwords, they mean, roughly, "anyone who can't get it up as often as he wants." Armed with billions of dollars and a good acronym, Pfizer set out to convince the world that ED is a disease and therefore that insurance ought to cover Viagra.
Pfizer is exploiting the defective assumption that medical insurance should use conceptual analysis to allocate coverage: We're here to treat disease. So, is X really a disease? For real, now...Well, okay then, I guess we'd better make some room on the forumulary.
Allocating insurance coverage based on the alleged reality of a disease plays into Pfizer's hands. They supplied a ridiculously expansive definition of ED, and we accepted their terms. If we concede that ED is a disease, we "diagnose" a lot of men who aren't sick by any stretch of the imagination, e.g. the 25-year-olds who who pester their doctors for a little "insurance" of their own. But within Pfizer's frame, we can't deny that ED is a disease without giving insurers an excuse not go cover ED meds even the most severe cases.
The ED debate is just one of dozens of fruitless arguments about whether an alleged disease is real. We're all familiar with the ADHD wars, the Autism spectrum skirmishes, and the battle royal about whether severe PMS is really premenstrual dysphoric disorder. These arguments are usually pretty confused. Ultimately, these disputes come down to insurance coverage. If you've got a recognized disease, you've got a claim to health insurance.
There are difficult decisions to be made, but splitting hairs about the "reality" of disease is pointless. We don't even have a rigorous definition of "disease" to work with. Better to remain agnostic about whether certain controversial clinical entities are "real diseases" and focus instead on the costs and benefits of the available treatments.
The fact is that we have clinical solutions for symptoms like impotence and hyperactivity. The question we should be asking is whether it would be a good use of our finite resources to cover these treatments.
A public health insurance system doesn't need to draw sharp a priori distinctions between treating the diseases of individuals vs. conferring other benefits to society. We still have to ask whether it's effective, expedient, or fair to address a particular problem through the health care system. Creeping medicalization is bad, but we don't need an arbitrary standard of disease to combat it. We are only vulnerable if we also assume that every treatable condition must therefore be addressed by medical care for individuals. Even if something's a disease, it may be still more appropriate to address the problem through public health, economic policy, educational reform, or some other means.
Private insurance companies want to draw as many lines as the can. Sophistry is profitable if you can convince your customers not to demand birth control coverage because contraception doesn't treat any diseases. Public health insurance needn't obsess over this boundary. It's convenient and cost-effective to include birth control in a public health insurance program, so it's irrelevant whether this kind health care falls under a preconceived mission statement delineating the scope of medicine.
The same principle applies to Viagra. The drug deserves to be considered for formulary coverage because it's an effective treatment for a troublesome physical symptom. Whether Medicaid covers Viagra should depend entirely on how the costs and benefits of the drug compare to other agents competing for a finite budget.