Friday, August 28, 2009

Confessions of a Health Care Rationer

Written by a medical oncologist who does consultation work for a private insurance company, this is perhaps the best discussion of how health care is currently rationed and what, if anything, can be done about it. An excerpt: (but read it all since an excerpt does not do it justice):

Limiting health care’s availability by the criterion of personal wealth rightly offends our sense of the dignity of the individual. Are the lives of the poor not of the same intrinsic value of those of the wealthy? To be fair, it is rare in the United States that poverty alone prevents the uninsured poor from receiving lifesaving intervention in a healthcare crisis. A poor man having a heart attack is not turned away from the emergency room, nor is the poor woman in labor sent away to have her baby at home. (I am not arguing that such enormities never occur, but the fact that such occurrences remain scandalous and newsworthy is a testament to their rarity.) Yet it is equally undeniable that the poor get a lesser share of the preventive care that can maintain health or of the quotidian care for the less dramatic challenges to their health.


All modern societies ration health care. A wise society considers the options and chooses a method of doing so which best conforms to its values and capabilities. Thus we come to the terrible question we would so very much like to avoid: How shall we ration health care? How shall we explicitly ration it? So noxious a question is this, so offensive in its tacit assumptions and implications, that most politicians and wishful thinkers will deny that we need to address it at all. They will argue that the fundamental problem is one of distribution, not one of unmeetable demand. They will argue, with more enthusiasm than evidence, that an emphasis on preventive care would substantially reduce aggregate demand. Some will say we must reduce the role of government; others will argue that we should augment it. If only we will adopt their plan—they’ll say—waste, fraud, and abuse will be abolished. There will be chicken—or at least chicken soup—in every pot, and a vaccine in every arm. People love honesty, but they hate the truth. To frankly acknowledge and address the ineluctable reality of healthcare rationing is not merely to touch the proverbial third rail of American politics; it is to lie across the tracks in front of the onrushing train.

Come, let us speak of unpleasant things. How is health care to be rationed? Who gets the short end of the stick?


On its face, one might think that the question of medical necessity is best answered by the physician who is actually taking care of the patient, rather than one who has never met him and is basing his decisions on a limited amount of information. But that will not do. That thought is one of the many illusory ways of denying the inevitability of rationing. To have the providers determine medical necessity is to have no limits at all on expenditures for health care, since all providers at all times believe (or at least claim) that the service they are providing is medically necessary. To have the providers be the arbiters of medical necessity is to abjure rationing altogether. The insurance company that does that will be very popular—very briefly. Then it will either go bankrupt in short order, or sharply adjust its premiums upward to have its income match its hemorrhaging outflow. If premiums rise enough, people will not buy the insurance. The result will quickly be the most generous insurance policy that nobody can afford.


As Congress and the people consider restructuring the American healthcare system, they must keep in mind that rationing health care may not be undeniable, but it is unavoidable. To claim that Congress will devise a new federal healthcare plan that will not involve rationing is like claiming that it will invent a triangle that doesn’t have three sides. Currently, within the private sector of health care, we have a large number of private insurance companies vying for the business of their customers. They ration health care on the basis of evidence-based medical necessity. The Obama health plan, the details of which are still being worked out, will also ration health care. The alternative to that is an accelerated escalation of aggregate healthcare costs. But the single-payer system to which Obama’s plan will lead will have no competitor and no pressing financial incentive to please its customers. No competitor for the single payer means no alternative for the patient. We can reasonably expect that a single-payer system of rationing will be largely implicit rather than explicit, and governed as much by cost and political considerations as by medical evidence. Such a system would likely combine the fiscal responsibility of the Postal Service, the customer friendliness of the Bureau of Motor Vehicles, and the smooth efficiency of the Immigration and Naturalization Service.

Read the entire thought-provoking piece. I may disagree with his conclusions, but it certainly does not detract from his eloquent explanation of the way we must allocate the scarce resources of health care. Comparing single payer to only the worst aspects of the Post Office, Immigration Services, the Dept of Motor Vehicles, etc., is a low blow. Like health care, these agencies serve necessary functions within society, and in the case of the Post Office, a place is definitely reserved for private players (UPS, Fedex, etc.) who enjoy a profitable existence. Even the Medicare system has a competitive aspect in allowing private insurers to provide supplemental coverage.

(hat tip Megan McArdle, whose site is sure to have a vigorous debate in the comments.)


Anonymous said...

The only reason we still have a U.S. Post Office is because it is given monopoly access, by law, to your mailbox. Take that away and watch the price of your stamps take a nose dive.
The comparison is valid because, when we give the government the power to give us a health care "option," it soon will legislate advantages that accrue only to it and punish other providers.

Tony said...

Your concern over the public option becoming the preferred manner of insurance is valid. Experience has shown in our Medicare and other single payers (Canada, Britain) systems that for-profit companies do not have the economies of scale to reduce overhead. That's kinda the point.

The post office provided service, and still does, to addresses that are too remote for smaller private carriers to service. Even today, some private carriers use the USPS to carry to the endpoint address.

There's no law that prevents Fedex from delivering to any address, and some businesses put up a box for such deliveries.