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


Bob Hockett said...

Thanks for these well timed observations, Neil. It would be salutary, it seems to me, for all concerned citizens to say to themselves at least once: "*Every* good for which potential demand exceeds available supply is rationed, and the apt question is accordingly *how,* not *whether* it is rationed." Rational rationing, please, rather than irrational dread of an opaquely understood word.


Paul Scott said...

It should likely be pointed out that (I assume - and also assume Niel will tell me if I have it wrong)) when Niel writes "If by rationing people mean that they might find themselves wanting care and being told that they cannot get it..." he does not mean that "When a person shows up with cash and says 'I can pay for this procedure' that they will be told 'No, the government forbids us from taking your money. We will not give you the procedure you want.'"

Even in the most "extreme" form of single payer being discussed (or rather, not discussed), there has been no suggestion of eliminating self-pay or optional medicine. The discussion is only about to what degree the Government would replace Medical Insurance.

The Streets of Beverly Hills will still be lined with plastic surgeons and the wealthy will still be able to pay for health care more advanced, more experimental and more "optional" than the rest of us.

The difference would be (under a good, single payer system, again *not* being discussed) that the "bean counters" would move from a profit motivated private insurer to the government, which we hope would make these necessary judgments with different, and superior motivations in mind.

CEP said...

To only slightly paraphrase Nat Hentoff's book title on allocation of First Amendment rights and burdens (great title, flawed book):

Unrationed Care for Me, But Not for Thee

demonstrating that the "anti-reformers" don't understand either the initial position (economically, the endowment effect) or veil of ignorance.

Jonathan Noble said...

Today's WSJ had an interesting article on heath care rationing from rationing hawk Betsy McCaughey:

Dr. Emmanuel says all the cost savings in the health care bill are "window dressing" and that real savings have to come from redefining the physician's duty to protect the patient at all costs.

Is the bill really addressing cost savings that wouldn't result in too much rationing, or will the bill create even more rationing than what exists currently under insurance plans?

Neil H. Buchanan said...

Thanks to Robert, Paul Scott (who does NOT have it wrong, although he does misspell my name), and C.E. Petit. We're all obviously on the same page. Would that the politicians could figure this stuff out . . .

Regarding Jonathan Noble's comments, I would note first that only in a 24/7 political shouting match would someone as dishonest as Betsy McCaughey be given the time of day.

On the merits, I resist the phrases "too much rationing" and "even more rationing." We're talking about changing who gets what, and when, under what payment arrangements. That's not more or less rationing, it's just rationing differently.

Emanuel's point is most obviously directed at end of life care, which absorbs an unbelievably large amount of health care resources as we allow (and in some cases, require) doctors to take "heroic" measures to keep someone alive for a few more months, or days, or weeks, or even hours. This subject is understandably disquieting, because it forces us to think about letting go; but it is also true that we are engaging in sometimes outright cruel measures to keep the dying alive. Maybe it wasn't such a bad idea to finance counseling for end-of-life decisions after all.