Thursday, August 27, 2009

Rationing and Rhetoric

In my FindLaw column this week (posted here), I step away from the public vs. private insurance debate and analyze critics' claims that the Democrats' plans for health care reform will result in "rationing" of medical care. The answer is that there will indeed be rationing, but it will not result from any reform that might be enacted this year. Rationing is a fact of life in every economy, capitalist or otherwise, and it is certainly a part of the health care system that we have today. If by rationing people mean that they might find themselves wanting care and being told that they cannot get it, then that is surely a possibility in any system of medical care that we might adopt -- but it is a cold reality for tens of millions of people today.

Whenever a political debate begins to focus on the definition of a single word, there is always the danger that the word will be defined into oblivion. Thus, years ago during the Carter administration, Andrew Young, an African-American who was U.S. ambassador to the United Nations, created a controversy when he said that former presidents Nixon and Ford were "racists." He then extended that description to all Republicans, including Abraham Lincoln. Even in a pre-cable-news era, this led to loud denunciations and pressure on President Carter to ask for Young's resignation. Within days, Young announced that all he had intended to say was that these men "took race into account" or something like that. In a classic move, he tried to define his gaffe away by draining the word of all meaning.

Is there an analogy to the debate over rationing? While it is true that all health care systems have to ration medical care in one way or another, is there some more narrow definition of rationing that has more bite than merely "some people don't get all they would like"? It is certainly possible to set up rationing systems in ways that do not feel as much like rationing. For those of us who are old enough to remember course registration prior to on-line catalogues, memories of lining up in front of folding tables in gymnasia and lecture halls might not count as nostalgia but certainly defined this time of year for our younger selves. College students today are not being turned away from their desired courses (victims of rationing) any less frequently than before -- in fact, they are probably having a harder time getting into the classes they want, given budget cuts and reduced teaching loads -- but they probably have a better experience in signing up for courses than we had.

In health care, one of the most common attacks on universal plans elsewhere is that people "end up on waiting lists" or "wait in line." That, however, is true today in the American system. We have to wait to have procedures approved for coverage, and many people are required to see a "gatekeeper" before seeing the actual provider who might be able to help them. Moreover, nothing in the current legislation would impose requirements that would make such waiting in line any more literal than is currently the case. Under any proposed reform, being told whether we will receive coverage is no more likely to require sitting in line than before. There will continue to be virtual lines in which we wait, but there is nothing under discussion that would turn our system into more of a big waiting room than it already is.

As I point out in my column, the closest thing that the current proposals have to a "rationing board" -- and this is a pretty long rhetorical stretch -- is the panels of experts that would attempt to determine the effectiveness of various medical procedures. In the nightmare scenario, these panels would decide that some procedure is too expensive or insufficiently effective for large numbers of people, resulting in decisions to deny coverage to individuals who might be helped but who are deemed expendable by the faceless, soulless bureaucrats.

Again, however, that nightmare is already our reality. Those boards exist today, run internally by every health insure company, and they regularly deny coverage to individuals and disapprove coverage of "experimental" medical procedures, etc. Because health care must be rationed, this is inevitable. The worry, backed by substantial evidence, is that these decisions are not being made on the basis of medical effectiveness or even cost-effectiveness in the broader sense but on the basis of short-term profits for the insurer. The proposals to impose scientific review on certain medical procedures and drugs are intended to move health care resources away from the profitable but ineffective interventions that are favored by the current system.

These reforms, if adopted, would surely be imperfect. They would not, however, be any more like rationing -- in either the broadest or the narrowest sense -- than today's system. The debate is not over whether we will do something that will lead to rationing. It is over whether we can ration health care more effectively and humanely.

-- Posted by Neil H. Buchanan