Sometimes health care should be rationed


The answer to the question of whether health care will be rationed under health care reform depends on how you define rationing.  Congressional staff have admitted to me that once all the effectiveness research is complete (to be conducted using the Medicare population experience), there will be treatment guidelines that will result in recommendations that certain care at certain times under certain circumstances may not be warranted and ultimately not paid for by government programs.  Therefore, the short answer is yes, health care will eventually be ” rationed.”

The people working on this legislation know this, experts in the field know this, but they do not trust the American people to accept or understand it.  Frankly I do not think that is an unreasonable position  nor do I think the objective is a bad one.  The flap over a section of the legislation that would provide for end of life counseling as a reimbursable expense under Medicare is ample proof of the sometimes-irrational reaction to health care that we all have (more recently the airwaves a full of chatter about the “Death Booklet” from the VA). Of course, if I was 97 years old and knew I needed a pacemaker but was not going to receive it, I may feel differently.  On the othe rhand, if I was 97 and knew anything I would be happy.

However, the real point is that to achieve that illusive “affordable” health care system something has to be done that requires the best use of resources.  The other problem of course, and this is true in England, is that those who can afford the care anyway or can afford to buy supplemental coverage will receive the care denied to others who are not able to afford more than a public system.  In other words, a two tiered system (which I assume is not the objective of our liberal friends).

As further evidence of the sometimes-skewed view of health care value and cost, many employer plans and the House bill HR 3200 provide full reimbursement for wellness and preventive services.  In a rational environment, one would expect that routine expenses, generally modest expenses and things that we should do to protect our families and ourselves are not insurable events.  When I was raising my children in the 1970s, my health benefits did not pay for well baby care,  immunizations, or orthodontics but providing them was a no brainer. If I had trouble paying for them, something else was not purchased; there was no question or discussion about it (which may explain why my four adult children still remind me that I never took them to Disneyworld).  Today, we seem to believe that every penny of incurred expense for health care no matter how minor or whether medically justified is somebody else’s responsibility.  On the other hand, there are well over 150 million cell phones in the US with an average bill of $53.00 (2002 data), so there must be many average Americans who cannot afford a flu shot for the kids, but can afford a cell phone.  There is every reason to believe that Americans cannot make rational decisions when it comes to health care nor do they understand the complexity of the system.

The bottom line is that unless we find a way to ethically ration certain health care services or more correctly, assure that we provide only appropriate services for the circumstances, we have no hope of affording health care. 

There are many concerns with the current health reform initiative starting with the bogus need for a public option, but comparative effectiveness research and its possible outcomes is not one of them.

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