Friday, August 28, 2009

Rationing health care

It’s a mistake to think of health care as a right. It is not a right; it is a good. ... There is an insufficient supply in this world to meet the demand of those who would have it. ...

Given the limited amount of health care that may be bought with the aggregate funds of the group, this untrammeled demand for it must always result in rationing. This is true whether the collective effort is a private insurance plan or a government program. Rationing is inevitable in all collective health care financing schemes.

Rationing must occur, but it need not be admitted. Denying the truth of rationing is more common in government-run health care schemes than private ones, because the government is reluctant to have the people know this ugly fact. Government-run programs, therefore, are more likely to disguise the rationing. This plausibly deniable form of limiting health care is called implicit healthcare rationing, and it assumes many forms. Rationing by termination occurs when patients are discharged from the hospital earlier than is medically optimal. Rationing by dilution occurs when second-best rather than first-best treatment is provided. Rationing by rejection or redirection involves healthcare providers turning away patients whose care will be inadequately reimbursed. This is commonly seen now in the Medicare and Medicaid programs, because those programs reimburse providers at a rate substantially lower than private insurance plans. Perhaps more common than those forms of rationing is rationing by delay, as exemplified by the outrageous amount of time patients in Canada must wait for hip replacement surgery or colonoscopy. The unifying theme in all these forms of implicit rationing is that, without admitting it, they force some patients to forego medical care that they want and are ostensibly entitled to receive.

Private insurance plans sometimes include an element of implicit rationing, but because they are, at heart, contractual agreements between the insurance company and the insured are more likely to ration health care explicitly. ... The advantage of explicit over implicit rationing is obvious: It gives potential customers of the insurance plan information to use when deciding which insurance plan to buy, and gives them clear expectations of services to be delivered. Implicit rationing, by contrast, may have the sweetness of a promise, but is usually succeeded by the bitterness of a promise broken. ...

Come, let us speak of unpleasant things. How is health care to be rationed? Who gets the short end of the stick?
--Medical oncologist Eric Chevlen, First Things, on the inevitability of rationing

7 comments:

Anonymous said...

The same logic could be used to make an argument against the public education system here in the United States. (or at least I fail to see a difference)

And, yes, I agree there are limited resources and we should decide how to best allocate these resources. But, surely a proper allocation of these resources demands that nobody be left behind? That we have enough wealth as a society where the education, the health and the safety of a society is not only possible, but imperative?

I think we can all agree that health care is not a right in the sense that freedom of speech is say a right. But, surely we must recognize the need to help those less fortunate. And, surely, we must realize that it is now possible for us, as a society, the basic tools to pursue happiness (education, safety and health).

Anonymous said...

to provide the basic tools to pursue*

James Choi said...

Who says we don't ration education in the public school system?

Anonymous said...

No, that's true, but I think most people would argue that the public education system in the United States is a good thing.

James Choi said...

Just to be clear, EVERY material good and service in this world is rationed. That's just what happens when wants are unlimited and resources are limited. In a capitalist society, most rationing happens through the price system: you stop consuming something because you can't pay for it. Some goods and services are rationed by government fiat.

So saying that health care (and everything else) is rationed doesn't mean that providing a certain minimum level of health care to everybody isn't a good thing.

Anonymous said...

Ok. My bad.

Justin said...

Chevlen's post seems misleading to me. Although the terminology of direct vs. indirect rationing is technically correct, it doesn't jive with what the lay person considers rationing of medical care. As a result, Chevlen gets the argument exactly backwards.

When the lay person thinks of rationing, he envisions long waiting lines for care in the UK and Canada--in other words, rationing is associated with publicly provided or financed care. In contrast, most people overlook that the current system in the US rations by price. Although people are well aware that many Americans are uninsured, they fail to see this as a consequence of "direct" rationing.

So, I agree. Let us speak of unpleasant things... especially the way that the US system rations care based on ability to pay, leaving millions without a reliable source of care.