A Vancouver Province news story last month indirectly raised one of those health care issues no one wants to talk about.
Cutbacks would mean 2,450 fewer surgeries in the Lower Mainland, the article said. The excuse was the Olympics, but really it's a cost-cutting measure. (Otherwise, the lost surgeries could have been made up during the rest of the year.)
The reporter found people to put a human face to the story.
One woman said she urgently needed a new hip. "I'm in pain, but the medications they give me for pain make me sick," she told the reporter. "I'm confined to a wheelchair when all I need is hip replacement surgery."
She hasn't even been given a possible date for surgery because of the "Olympic slowdown."
Here's what stopped me. She was also 91.
Health care remains affordable; governments have just been reluctant to allocate the needed money, judging lower taxes a bigger priority. With good management and system reform, it will remain affordable. (Though we're lagging on both counts.)
But rationing care is part of the reality in the near term, longer if we don't improve efficiency.
And the notion of a hip replacement for a 91-year-old raises questions about just how we're going to decide who gets care.
Right now, it's informal. Specialists and committees make judgments about who should be treated first based on urgency and other factors.
Some people are constantly bumped down the list. It's tough to have confidence in fairness. (And of course, people with money pay for private care - supposedly illegal - to avoid rationing.)
We need to talk about the process honestly, to improve fairness and cost-effectiveness and to allow informed decisions about the current level of rationing.
The issue is sensitive. But better to discuss the criteria for rationing than to allow it to happen without any public input or assessment.
It doesn't need to be - shouldn't be - entirely arbitrary, based on age, for example.
But take a person of 91 in the queue for a hip replacement. A new hip can last 25 years. So spending the money on a 40-year-old buys many more years of benefit. The risks of complications or an unsuccessful outcome also rise sharply, according to recent studies.
Ideally, we decide both deserve timely surgery so they don't suffer and live shrunken lives.
But if that won't happen, we should be upfront about how and why the decision was made.
The discussion alarms people. For instance, should people who are seriously overweight have the same access to knee and hip replacements?
It's not a moral judgment. The surgery is riskier, outcomes poorer and the artificial joints don't last as long. A few years ago, some British National Health managers faced a budget crunch and quit doing knee and hip replacements for anyone with a Body Mass Index over 30. If you were five feet nine inches tall and weighed 205 pounds, no new hip until you lost weight. (Some doctors in B.C. take the same approach, but the system doesn't.)
The British National Institute for Health and Clinical Excellence looked at one of the most controversial rationing questions. What if the patient's illness is self-inflicted?
Should a child who needs a liver transplant wait in line behind someone whose illness is caused by years of alcohol abuse? After all, addiction is a disease.
The institute decided that what mattered was not past behaviour, but future prospects. A child with a new liver thrives; an alcoholic, statistically, is at high risk of returning to drinking.
This all started with the 91-year-old waiting for a hip transplant. But there are two issues. When do we want to say no treatment for you. It's not worth the money.
And how will make those decisions.
Right now, we pretend they aren't being made. That's cowardly, and it's keeping us from a serious health care discussion.
Footnote: Here's one of the most interesting numbers. Of all the health care costs you occur in your life, 35 per cent will typically come in the last six months. And then you'll die. Beyond efforts to improve your comfort, it hardly seems smart spending.