Wednesday, September 19, 2012

Rationing is not a four-letter word

This morning a friend wrote on Facebook about his expensive medications. He's grateful that Obamacare will make them more affordable. "I do have a twinge of bad conscience," he added, "about the cost of my health care coverage." Maybe death panels are a good idea?

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.


Ellen Painter Dollar said...

Thank you LaVonne! This is very helpful to me. I think I'll link to it for my regular Friday post in which I promote someone else's blog for a change. I still get a bit nervous about those decisions about what is "necessary" or not. What an insurance co. bureaucrat, or even a medical person who hasn't done his/her research, considers necessary or not might differ greatly from what I or a more fully educated practitioner believes is necessary. For example, I take prescription narcotics for pain control, and given the bad rap these drugs get because of their addictive potential, even among many doctors who see them as necessary only in very limited cases, I'd be afraid that someone would ration me right out of the medications that allow me to live a full and active life. That said, I agree that rationing already occurs and that we need to figure out a way to do it as equitably as possible.

Miriam said...

“limiting legal liability so insurance payments don't drive doctors out of business”

I have to strongly disagree with this one point. Even in places (like Texas) where there are laws that limit legal liability of doctors, malpractice insurance rates have gone up. The vast majority of medical malpractice suits are filed against the same small group of doctors over and over again. What we really need is better accountably for how doctors treat people. I would argue that if it was easier to get rid of bad doctors and change some aspects of medical education to include teaching things like listening skills and bed side manner, we would have less need for massive medical malpractice insurance. Doctors in other developed countries don’t pay nearly what ours do in medical malpractice insurance, we can look at what they do and use those ideas.

LaVonne Neff said...

I would love to know more about how other developed countries limit malpractice costs, Miriam. Can someone refer me to books or websites on the topic?

Anonymous said...

Thank you for your numerous helpful posts on the health care system. Back in the early 90s when Hilary Clinton was leading a panel looking into reform, I was totally against it.

Since then, I've done a 180. The reason: my husband has been unemployed, more than employed, over the last 10 years. We've had to purchase health insurance entirely on our own nickel. Very expensive! The deductible is now up to $3500, which means you skip having necessary care done.

It affects churches too. I recently learned from a neighboring church administrator that a youth pastor candidate turned down their job offer. The church would pay his health insurance, but not his wife's. It would take 1/3 of his take home pay to cover her premium. So he accepted a job somewhere else.

LaVonne Neff said...

Wow. And the youth pastor was more fortunate than many, because he was able to find another job with benefits. Thanks for your story, and I hope the Affordable Care Act does indeed make your health care affordable, soon!

Anonymous said...

(my name is LaVonne, too).
As a Canadian, I can't understand why a medicare plan such as we have is not feasible in the USA.
As a a retired person, I pay $65/mo. When I was working, it was less - employer paid a touch more than half.

Since 2008 I have had two major operations which didn't cost me anything except $35 per day for a private room in the hospital (my choice...a 4-bed ward would have been free).

Moreover, no charge to Canadians for doctor's office visits. We don't have to delay need for care, might save worsening condition.

We have a population of less than 35 million. Our population can support a universal healthcare plan. The USA has more than 10 times the population of Canada. Surely 350 million people can support a universal health care plan successfully - many more people to pay into it, and as well, more healthy employed people than sick people by far to support the plan, I should think.

By the way, my $65/mo covers 60% of my dental care, too, however this is an option my former employee-plan (union job) allowed me to take. If I'd wanted to pay in more, I could have opted for 80%dental coverage, or 100%. Medicare without the dental would cost $57/mo.(rather than $65).

Do you think that if your legislators could corrall Big Pharma and Big Insurance Co., that maybe your country could get something even better going? The current Obama-care is not the whole way your President wanted to go (he wanted something more along the lines of the Canadian plan) but he was hog tied, he had to compromise.

We are not socialists in Canada. We have a capitalist system, too. However we don't fret at the thought of socially subsidized provision for people's health, and I think as a consequence we might have a healthier population. The Native Indian people in Canada have totally free healthcare - they don't have to pay any monthly premiums at all.

LaVonne Neff said...

Dear Anonymous LaVonne in Canada - What a helpful comment! You inspired me to compare what you pay to what I pay, and then to check out the facts about Canadian health care. I hope you don't mind that I quoted your whole comment on my blog. You can read my new post here:

Anonymous said...

from Anonymous LaVonne in Canada

Thank you for your response. I wasn't sure if it would be appreciated or not.

The following is a web page showing several links to The Canada Health Act on which our universal medicare system is based.

In 2014 an Accord between our federal government (Prime Minister Steven Harper, Health Minister Rona Ambrose & etc - rest of Harper's governing Conservative Party) will be renegotiating terms with the provinces. The Council of Canadians headed by Maude Barlow an intrepid political activist has much information for Canadians on this and a good web page where on the right you will see a bar with helpful links, e.g., for your information, see "Factsheet: Understanding the Canada Health Act". Here is link to that web site:

I hope this is helpful in your undertaking to get some knowledge about our Health Act. Perhaps some of your blog group will get inspired, too.

It's disheartening how the USA is going through several crises at this time, with Syria-Iran, the debt ceiling deadline approaching (Oct 17) and gov't shutdown over Obamacare. I hope the good people will get their voices heard and good sense prevail in all these things.

Anonymous said...

LaVonne from Canada again.

Oops, sorry. I sent you some links to Canada Health Act before I read your new post at

I see there that you have already done a fair amount of research on the Canada Health Act and appreciate that you attached several helpful links on there for your readers.

LaVonne Neff said...

Dear LaVonne-in-Canada,
Our post has been reposted on Sojourners' website. Thought you'd like to see it, so here's the link.