President Dale Durham is months into her 2nd term
as President. The feature accomplishment of her first term was getting a
nationalized health system in place. Her 2nd term begins the
implementation. She was an interesting candidate four years earlier. She and
her husband were childless, but she became pregnant just after being nominated
by her party. They withheld news of her pregnancy and revealed it at her
inauguration. Early in her first term, she gave birth to a son.
Upon enrollment into this new system, each patient must give
a blood (for blood banking and compatibility testing) and tissue sample (for
DNA). Implementation of the nationalized health system is not without some
expected snags. Chief of which is that government payouts to physicians and
hospitals far exceeds expectations. The program’s head and its regional directors
are forced to cap payments and order reductions in clinic hours. Operating Room
times are slashed. Small to medium size hospital ERs are closed on weekends and
also have to close their doors for 4-8hr/day, usually overnight.
But perhaps the biggest realization is that when patient
needs far exceeds the capability of the medical system to provide,
prioritization and rationing has to be imposed. And that means what was once a
theoretical argument must be put in place.
A Tier system defines priority categories for each citizen:
Tier 1 includes ‘high ranking government officials’, industry moguls,
scientists, and celebrities (entertainment, sports, media). Families of those
are also included. Tier 2 is made up of military officers, federal employees, health
care professionals, attorneys, land law enforcement. Again, families are
included. Tier 3 is anyone else. (but after initial implementation, the
regional head from California convinces the other regional heads that a Tier 4
needs to be added. This would be any non-citizen).
Then, each person will have a Treatment Eligibility Score (TES)
determined. Start with a Tier score (T1=0, T2=100, T3=300, T4=400). Now add 10
points for each decade over 50. Then more points for various chronic conditions
in their medical history, with more points for ‘lifestyle’ diseases like
obesity, smoking, substance abuse, and more. The resulting TES is then used to
rank patients when requesting further diagnostic testing, elective surgery, and
costly treatments. The lower your score, the quicker one gets service or
treatment. The underlying philosophy is that healthcare is prioritized for
those who can give the most to society. Old and infirm are at the end of the
queue.
A scientist responsible for groundbreaking discoveries in
the treatment of emphysema needs a lung transplant. A Senator needs a new
kidney. And most heartbreaking for the nation, the President’s son has
developed a cardiomyopathy that requires a heart transplant.
The health system database ha been set up to mine the
genetic and molecular information to find potential donors - a national donor
list. But when transplant demand exceeds supply, it’s now possible to mine the
database and find someone with a high TES (meaning last to get treatment for
anything). A very small group under the control of the program’s chief medical
officer finds an eligible person with little or no family ties, snatches them,
sedates them, and tests them for compatibility. If not compatible, they are dropped
off at an ER as the sedation wears off. But if they are compatible . . .
The scientist get his lungs and the Senator gets his kidney.
The President’s son? Still looking.
That’s where a parallel story comes into play. Dr. Sand, an
internist (Tier 2), his wife and daughter, fed up with DC life, move to rural
Pennsylvania into a German Baptist community. Much like the Amish, but they do
drive and use electricity. Dr. Sand’s sister is a database administrator for
the new nationalized health system. His brother is a DC detective who
investigates missing persons (and he’s getting the hots for a local widow). The
strange kidnappings around the country eat at the detective and the details of
the TES formula raise ethical issues with the sister.
Ergo, the intersection of the two stories. Shouldn’t take
you long to figure out the basic details of how these two stories intersect.
Set Apart was first published in 2010 and I can only guess
that it didn’t sell well with reviews saying It was overly long with excessively
drawn out descriptive text. The 2nd edition’s forward says that McCall took those comments
to heart, shortened the book to tighten up the story and his publisher is
re-releasing it in 2019.
This is really two stories in parallel. One is a medical
mystery and the other a coming-to-grips-with-life story. For some, this will be
an interesting set of parallel circumstances intersecting late in the book. For
some.
Not so much for me. The medical mystery is a cautionary tale
of an abuse of a nationalized health system. Could it happen? Theoretically, I
guess it could. Practically, I doubt it because I suspect that a nationalized
system would have multiple safeguard layers and firewalls to allow such an
egregious misuse of what most everyone accepts is the highest level of personal
privacy. Then again, I could just be naïve. The coming-to-grips story seemed
just too easy of a change in life for the Sand family. A well-to-do family from
DC up and moving to a near-Amish setting and becoming as close to the locals as
an outsider can? I just didn’t buy it. Maybe this German-Baptist enclave isn’t
as cloistered as the Amish. I found myself skipping long segments from Pennsylvania
because, to me, they were presented simply to set a stage for Dr. Sand’s family
to be caught in the system’s database net. Might have been more interesting if
there were more examples of overreach of the for the police, appalled doctors,
and computer hackers to detect. It came down to this: Are the nuances on one
family’s life enough to carry the story or would it be more interesting for
multiple instances of transplants for The Privileged (Tier 1s) at the expense
of the Tier 3/4s make for a more compelling tale?
ECD
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