Why 'Rationing' and 'Rational' Feel so Different. The REAL Reason for the Health Care Cost Crisis.

     Suppose you have a disease…an incurable fatal disease…and a drug has just been approved that can treat that disease. The drug only works in about half the people who get it, and all it does is lengthen their lives by an average of 4 months. Side effects include diarrhea, nausea, rash, and fatigue. Still, you couldn’t get your hands on it fast enough.

     But suppose the drug costs way more than you can afford, and suppose that insurers won’t cover it because, they say, the drug does not provide ‘cost-effective’ use of health care dollars. Cost-effective!? How DARE they! How DARE some number-crunching, penny-pinching, cold-hearted bureaucrats decide what you can and can not have that might lengthen your life!!!! How dare they decide who lives or dies, based on money!!!

     Welcome to the United Kingdom, where the government oversees the health care system, and where the National Institute for Clinical Excellence (NICE) that reviews drugs and treatments for the government has just recommended that the $126,000/patient cost of Yervoy, a new drug that can prolong the lives of some people with advanced, inoperable (and usually fatal) melanoma, is too high and that it doesn’t provide enough health care bang for the buck so the National Health Service (NHS) shouldn’t cover it. If the NHS takes that NICE advice, some people in the UK with advanced inoperable skin cancer who can afford Yervoy may live a little longer. Some who can’t afford it, will die…a few months sooner than they might have.

     Ugly, huh, putting a monetary price on life? But now let’s change the shoes you’re wearing. Let’s say you’re not the patient. Let’s say you’re in charge of the health care system, and you’re asked to choose whether to cover a drug that can treat some terrible fatal disease, but which only prolongs life by a few months, and only in half the patients who get it, and many of the patients who are helped live those extra few months vomiting and weak and covered in a rash. And the drug costs so much, per person, that approving it for coverage will mean insurance rates for everybody in the entire system will have to go up, to cover the costs. Now what do you think?

     To a patient, approving or disapproving coverage of health care based on a comparison of costs against benefits is rationing, in all that word’s ugliest meanings...’denying choice’ and ‘death panels’ and ‘murder’. But to everyone suffering in one way or another from the excessive cost of health care – which is most Americans – this sort of decision making is rational, in all the positive meanings of that word…wise, thoughtful, balanced and fair. Interesting, isn’t it, how the tiny difference in those two words – ‘rationing’, and ‘rational’ – belies the great gulf between what each implies. In that gulf lies the heart of the difficulty in solving the health care cost crisis.

     It’s pretty obvious that the system can’t afford everything. Analysis of health care benefit- per dollar of cost is one way the UK and other health care systems are using to face that reality. The U.S., where ‘freedom of choice’ and ‘land of opportunity’ are so intrinsic to our self-identity, has not found a way to confront such tough choices. So;

   - We spend more than twice as much per person for health care - $7,538 - as the average of all the other industrialized nations - $3,060.

   - More than one dollar in four that the average American family earns (median income - $50,000), goes to health care! (average family health care spending - $18,000).

   - From 1999 to 2009, the inflation rate for health care in the US rose 60% faster than inflation in general.

     There are many reasons for this crisis; the way doctors and hospitals are paid (per procedure, incentivizing more care), the costs the uninsured create when they get emergency room care everyone else has to pay for, obtuse billing systems that hide the true costs from the consumer. True as all these reasons are, they fail to recognize the core truth that lies at the heart of the health care cost crisis, the real reason we have not had the courage or wisdom to find a way to make hard choices…the reason why ‘rationing’ and ‘rational’ can feel so night-and-day different. Comparing costs and benefits may be rational, but human risk perception is not. The way we judge danger, and figure out how to keep ourselves safe and alive, is not a purely fact-based, coldly objective process of cognitive analytical reason. It is a subconscious, instinctive, emotional process, the principal objective of which is not to serve some greater common good, but to keep each of us alive. The ‘thinking’ part of our brain may accept that the system can’t afford everything for everybody, but the thinking part of our brain is only one part, and not the most influential part, of the way we figure out threats to our health and safety. Ultimately risk perception is a mix of the facts and how those facts feel, and the brain puts more emphasis on the feelings than the facts.

            And so rationing, as much sense as it might make intellectually, upsets us because it threatens us. It literally viscerally threatens us. Never mind that the health care cost crisis threatens us too. Those threats - to our ability to afford the comprehensive health insurance that would give us access to every medical option, to our family budgets, and to the prices of all the goods and services produced by businesses which pass along their cost of providing health benefits for workers - don’t seem as immediate, don’t feel as real, don’t feel as threatening, as it feels to have advanced inoperable melanoma and to be told that the government won’t help you pay for a drug you can’t afford, that could prolong your life.

            So what will it be? Freedom of choice, or rational rationing? Yervoy (and any drug or treatment that has even minimal benefit) for all, and the expense be damned? Or prioritizing coverage for care that yields the most health bang per buck, because otherwise, the cost of the health care system – which we all have to pay one way or another – will create bigger and bigger risks of its own? Until the debate about the cost of health care in America honestly confronts that choice – and the realities of human risk perception that make it such a difficult choice – we won’t be on a path to true solutions.                       

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Homo sapiens have been on earth for 200,000 years — give or take a few ten-thousand-year stretches. Much of that time is shrouded in the fog of prehistory. What we do know has been pieced together by deciphering the fossil record through the principles of evolutionary theory. Yet new discoveries contain the potential to refashion that knowledge and lead scientists to new, previously unconsidered conclusions.

A set of 8-million-year-old teeth may have done just that. Researchers recently inspected the upper and lower jaw of an ancient European ape. Their conclusions suggest that humanity's forebearers may have arisen in Europe before migrating to Africa, potentially upending a scientific consensus that has stood since Darwin's day.

Rethinking humanity's origin story

The frontispiece of Thomas Huxley's Evidence as to Man's Place in Nature (1863) sketched by natural history artist Benjamin Waterhouse Hawkins. (Photo: Wikimedia Commons)

As reported in New Scientist, the 8- to 9-million-year-old hominin jaw bones were found at Nikiti, northern Greece, in the '90s. Scientists originally pegged the chompers as belonging to a member of Ouranopithecus, an genus of extinct Eurasian ape.

David Begun, an anthropologist at the University of Toronto, and his team recently reexamined the jaw bones. They argue that the original identification was incorrect. Based on the fossil's hominin-like canines and premolar roots, they identify that the ape belongs to a previously unknown proto-hominin.

The researchers hypothesize that these proto-hominins were the evolutionary ancestors of another European great ape Graecopithecus, which the same team tentatively identified as an early hominin in 2017. Graecopithecus lived in south-east Europe 7.2 million years ago. If the premise is correct, these hominins would have migrated to Africa 7 million years ago, after undergoing much of their evolutionary development in Europe.

Begun points out that south-east Europe was once occupied by the ancestors of animals like the giraffe and rhino, too. "It's widely agreed that this was the found fauna of most of what we see in Africa today," he told New Scientists. "If the antelopes and giraffes could get into Africa 7 million years ago, why not the apes?"

He recently outlined this idea at a conference of the American Association of Physical Anthropologists.

It's worth noting that Begun has made similar hypotheses before. Writing for the Journal of Human Evolution in 2002, Begun and Elmar Heizmann of the Natural history Museum of Stuttgart discussed a great ape fossil found in Germany that they argued could be the ancestor (broadly speaking) of all living great apes and humans.

"Found in Germany 20 years ago, this specimen is about 16.5 million years old, some 1.5 million years older than similar species from East Africa," Begun said in a statement then. "It suggests that the great ape and human lineage first appeared in Eurasia and not Africa."

Migrating out of Africa

In the Descent of Man, Charles Darwin proposed that hominins descended out of Africa. Considering the relatively few fossils available at the time, it is a testament to Darwin's astuteness that his hypothesis remains the leading theory.

Since Darwin's time, we have unearthed many more fossils and discovered new evidence in genetics. As such, our African-origin story has undergone many updates and revisions since 1871. Today, it has splintered into two theories: the "out of Africa" theory and the "multi-regional" theory.

The out of Africa theory suggests that the cradle of all humanity was Africa. Homo sapiens evolved exclusively and recently on that continent. At some point in prehistory, our ancestors migrated from Africa to Eurasia and replaced other subspecies of the genus Homo, such as Neanderthals. This is the dominant theory among scientists, and current evidence seems to support it best — though, say that in some circles and be prepared for a late-night debate that goes well past last call.

The multi-regional theory suggests that humans evolved in parallel across various regions. According to this model, the hominins Homo erectus left Africa to settle across Eurasia and (maybe) Australia. These disparate populations eventually evolved into modern humans thanks to a helping dollop of gene flow.

Of course, there are the broad strokes of very nuanced models, and we're leaving a lot of discussion out. There is, for example, a debate as to whether African Homo erectus fossils should be considered alongside Asian ones or should be labeled as a different subspecies, Homo ergaster.

Proponents of the out-of-Africa model aren't sure whether non-African humans descended from a single migration out of Africa or at least two major waves of migration followed by a lot of interbreeding.

Did we head east or south of Eden?

Not all anthropologists agree with Begun and his team's conclusions. As noted by New Scientist, it is possible that the Nikiti ape is not related to hominins at all. It may have evolved similar features independently, developing teeth to eat similar foods or chew in a similar manner as early hominins.

Ultimately, Nikiti ape alone doesn't offer enough evidence to upend the out of Africa model, which is supported by a more robust fossil record and DNA evidence. But additional evidence may be uncovered to lend further credence to Begun's hypothesis or lead us to yet unconsidered ideas about humanity's evolution.