Wednesday, September 19, 2012
Rationing is not a four-letter word
Before cutting end-of-life care, I wrote back, we need to control costs. Otherwise "we are going to have to--gasp!--ration care, or soon only the very rich will be able to afford care at all."
A friend with osteogenesis imperfecta--and who has a child with the same condition--immediately jumped in. "Tell me more about what you mean when you talk about rationing care," she wrote. "As someone who requires fairly regular doctors' appointments just to function well, the idea makes me nervous."
The idea of rationing makes everybody nervous. Though one Merriam-Webster definition, "to distribute equitably," is what the propaganda poster above is trying to communicate, most of us think first of Collins's definition: "the process of restricting consumption of certain commodities." Hey, I need all of my office visits, surgeries, MRIs, echocardiograms, and prescription drugs. If my substandard aortic valve starts malfunctioning again, I don't want any bureaucrats telling me I'm allotted only one surgical intervention.
OK, breathe deeply. Let's look rationally at that word rationing (the two words do have the same root, which has to do with "reason").
1. American healthcare is already rationed. That is, not everyone can have all the healthcare they want. My insurance is very good, but it doesn't cover eyeglasses, adult orthodontia, or cosmetic surgery (darn!).
A lot of people can't even have all the healthcare they need. Healthcare providers tend to be more abundant in areas of high population density and high average income, so people who live in rural areas may not be able to see a top cardiac electrophysiologist in the middle of the night when their tachycardia acts up. If they live in health professional shortage areas, they might have a hard time finding a general practitioner.
2. American healthcare funding is also already rationed. The government rations the amount it reimburses Medicare and Medicaid providers. Insurance companies ration reimbursements to healthcare providers. Before the Affordable Care Act kicked in, some insurers also denied valid claims from people who were getting too expensive, or else they dropped those people's insurance altogether.
The bottom line always wears a dollar sign. If you have enough dollars, your access to healthcare is limited only by your imagination. I doubt if there is any form of healthcare that Bill Gates (net worth: $66 billion) couldn't afford. Americans whose yearly income is in the lowest 20% (less than $27,000), however, can afford almost no healthcare without insurance--and a quarter of them are uninsured.
3. The challenge is to find an approach to rationing--i.e., allocating--public funds so as to make healthcare more, not less, widely available to all.
One way to do this is through policies that increase healthcare resources and distribute them more evenly throughout the country. Other developed nations do this in many ways, such as offering low-cost medical education so physicians aren't burdened with debt; limiting legal liability so insurance payments don't drive doctors out of business; using single-payer or streamlined private insurance systems so administrative overheads don't force medical clinics to double or triple their costs; and putting cost ceilings on medications and medical equipment.
At the same time, we need programs that reduce the need for expensive health repairs by keeping people healthy in the first place. Adequate prenatal care, for example, can reduce expensive pediatric care for pre-term babies; and a healthy diet can prevent many cases of diabetes, heart disease, and cancer (note to Department of Agriculture: corn subsidies aren't helping).
But there are always more healthcare needs than healthcare funds ... even after we've increased healthcare resources and reduced the need for repairs. How do we ration our resources so that there is indeed "a fair share for all of us"?
Not by insisting that Bill Gates's healthcare must be no better than mine. Heck, his house and surrounding structures comprise 66,000 square feet, just a tad bit bigger than mine even including the basement. I'm guessing he eats in better restaurants and buys nicer clothes than I do too, and I expect he travels first class. That's what "rich" means.
So yes, rich people will get better healthcare than poor people, and people with good insurance will get better healthcare than people with barebones insurance or (heaven and the U.S. government forbid) no insurance at all. However, poor people also need shelter, food, clothing, transportation--and healthcare.
4. We need to get rid of our hypocritical notions about equality--which we aren't practicing anyway--and start thinking in terms of adequacy.
What if we had, say, a three-tier healthcare system?
The foundational tier would be publicly funded; the patient would pay nothing. If you need basic medical care--an immunization, a routine diagnostic service such as a mammogram or a blood test, meds for a cold or a urinary tract infection--you go to your local pharmacy or public-health clinic and get it done. Such an approach can be wonderfully efficient, cutting out whole layers of bureaucracy.
The middle tier would be funded by private, not-for-profit insurance, which everybody would be required to carry (publicly subsidized if they can't afford it). This would include all other necessary health care--and yes, someone would have to draw lines between what is necessary and what is not. Not every possible treatment would be available to everyone who wanted it. This is rationing, to be sure. We're doing it now.
But if we've done a good job of allocating healthcare resources and reducing the need for repairs, we should have more money to go around rather than less. (For examples of how this is being done elsewhere, see my August 29 post, "Four Countries That Already Meet the Republican Platform's Health-Care Goals.") My Facebook friend would still be able to meet her fairly regular doctors' appointments. In fact, if our reforms increased the number of physicians to a level similar to Western Europe's,* she might find it easier to get in.
The top tier would allow for unnecessary, but pleasant, healthcare. It would be funded by individuals either out of their own deep pockets or through for-profit insurance policies they've purchased. It could include things like private hospital rooms, private-duty nurses, the very latest designer drugs, face lifts, and hospitals with wood paneling and marble floors (sorry, CDH: I love you, but you do go overboard).
We Americans are smart. We could find a way to provide necessary medical care for everybody. Perhaps someday, when all our present Members of Congress have finally passed away, a totally new set of lawmakers will figure out how to do it. But first we're going to have to realize that rationing can be a tool used for the common good, or it can be a buzzword used to scare people who haven't noticed that haphazard rationing--our present nonsystem--is the cruelest approach of all.
*In the United States, there are 26 physicians for every 10,000 people. By contrast, there are between 27 and 35 physicians per 10,000 people in France, Germany, Ireland, Luxembourg, Portugal, Spain, and Sweden; and there are between 36 and 42 physicians per 10,000 people in Austria, Belgium, Denmark, Iceland, Italy, the Netherlands, Norway, and Switzerland.