An easy way to kill a debate on health care policy is to use the “R” word. We saw this early in the HCR debate with overheated talk of “death panels” and other nonsense. But we ignore the real issue of rationing at our own peril. Those of us who favor real HCR must embrace rationing, coopt it, show our opponents how it is inevitable.
Nowhere is the the Right more hypocritical than the issue of health care rationing (OK, maybe with sex stuff, but…). Everyone who studies American health care knows that we already ration; we just do it irrationally. Current rationing allocates resources to the wealthy and those with good jobs, and when we do care for the uninsured, unevenly spreads that cost to some hospitals and taxpayers. Medical services are reimbursed in an unstable fashion, with some services reimbursed well one year, and poorly the next, making planning nearly impossible for doctors, hospitals, and patients. For example, there are currently large cuts planned for some cardiology services, cuts which I don’t disagree with in theory but cardiologists cannot provide good service to their patients if one year they are encouraged to go out and buy lots of fancy equipment and the next year are told they can’t use it.
Hospitals struggle from year to year as economic downturns change the payor mix driving down income. There is no stability in our current system. It is not robust, for providers or for patients.
But explicit rationing—and we might as well use the word, because our opponents sure will—can help stabilize costs and improve the our health care system. Any doctor or nurse knows that ICUs are filled with people who will never walk away. Pandemic emergency plans recognize this, and if our current flu pandemic gets any worse, we will see limited resources allocated to kids rather than the hopelessly, terminally ill. Why wait for a pandemic? Comparative effectiveness research can help guide our policies. Do bed-bound octogenarians benefit clinically from hip replacement surgery? I suspect not, but if studies bear out my suspicion, shouldn’t we stop torturing them for cash and allocate scarce resources where they are needed?
Conservatives hate the idea of rationing—hell, everyone does, but conservatives especially because it cuts into our “freedom”. But “freedom” means nothing if you don’t have insurance. You’re only free to rot. I struggle every day to get care for diabetics who can’t afford necessary testing materials. This is basic care, not some high-end, experimental treatment. How can we, as a nation, continue to ignore basic prevention and proven treatments in favor of the libertarian fantasy that is our current system?
The Times just published a piece on paying for alternative medicine. It acknowledges that these treatments are unproven, but then goes on to tell consumers how to get them. There are practices about which reasonable people can disagree—at what age to start mammograms, at what age to stop colon cancer screening, etc—but to take our scarce resources and throw them away at acupuncture and herbs is narishkeit.
The first step in rationing rationally is to make the system transparent. Currently, if you are denied care, there is often no explicit reason given (except perhaps a pre-existing condition or your own poverty). To be ethical, rationing must be explicit, transparent, and understandable. We could start by rationing clearly unproven therapies, such as acupuncture and chiropractic. If people want them, then they can pay out of pocket. We can then move on to comparative effectiveness research on expensive mainstream procedures. ICU care for the dying might be a place to start. Even inexpensive procedures add of fast and may provide low-hanging fruit.
No one likes to talk about rationing, but if we are going to have a sustainable health care system in this country, we have to make difficult decisions. Let’s do it deliberately and in the open.