As President Obama’s health care plan is considered, one point of debate looms large. Should health care be rationed?
If you were a parent of a child whose life was about to end, you would desperately seek any measure, no matter how small the chance of such success or how expensive, to save her. I know I would. That’s what a parent should, must, do.
But that’s not how policy should work. It’s not the product of emotion and desperation, but one that can sustain the whole and provide for the welfare of a society of people rather than any particular individual within it. Science has sought to advance our ability to treat disease by developing heroic measures. This is good, and will no doubt inure to the benefit of society as a whole in the long run. It doesn’t mean, however, that we can ignore the allocation of scare resources, or that society can sustain a health care system that will provide every individual in need with any treatment possible at any time.
Here is a difficult concept to swallow. Everyone cannot be saved.
If we accept the proposition that there are not enough doctors, hospitals, medicine or cash to pay for them to allow every person in need access to every medical procedure available. we must accept the notion that care must ultimately be rationed. For every procedure that costs $100,000, how many poor pregnant women could be provided free, quality pre-natal care? Do we trade the health of those pregnant women for a chance that some ultra-expensive, low percentage procedure might save one child? What if the percentage of success was high, but the cost was $1 million?
As we sit today, the cost of health insurance is, frankly, outrageous. For those like me, who pay a multiple of our medical usage in insurance, financing the health of others who make greater use of resources, it’s already painful. I don’t take issue with the needs of other people per se, though I am troubled by those who undergo needless tests to keep a physician’s CAT scan operating 24/7 so that he can turn it into a profit center.
It’s similarly disturbing when some, like the elderly, use medical care as a social activity, enjoying inordinately expensive tests every time they get a twinge of pain, simply because medicare will cover it and they get to hang with the old homies while they wait for their turn. I’m not beating up on the elderly for fun, but in recognition that we’ve dedicated a great deal of resources toward the sentimental goal of extending life, with little thought of its quality or cost.
Our octogenerians view medicare as a right they’ve earned, but few would agree to pay for their care if they had ever been required to do so. It’s the disconnect between a fine sounding concept and a harsh reality. Would they really sacrifice their own grandchildren for an extra, needless, MRI? But they are never asked to think of it that way, as if the magic medical elves just produce medical procedures out of thin air rather than at the expense of their children and grandchildren. Some pays for it, folks. Just not you.
As much as I understand (and I most assuredly do) how a parent feels watching the pain suffered by their child, and can appreciate the desire to do anything, everything, possible, I similarly understand that our society would be required to dedicate an impossible amount of its resources to health care if we were to offer every conceivable treatment to anyone who needs it upon demand.
I don’t suggest that I know where the line should be drawn. But I do know that we can’t do it all, no matter how sad it is that someone may die even though there is a potential treatment available. I know that we trade off the extraordinary care for one for the ordinary care for many. I can feel the pain of a parent whose child’s life is on the line. I can also feel the pain of a parent who can’t afford basic health care for his child. And I understand that we cannot afford to do it all.
For anyone who thinks me callous, and it may be an accurate characterization, tell me how we pay for heroic health care when the cost will preclude the ability to buy food and clothing for a child equally beloved by a parent? It’s not that one child is less worthy than another, but that the cost of the extraordinary procedure has to come from somewhere. Who pays the price? What do we give up to make it happen? Something has to give.
I don’t see how we can do anything other than ration health care and survive. And I don’t like it any better than anyone else, but I realize that it must be. The real question is where to draw the line, but we’ll never get to that question until we, as a society, have come to grips with the fact that we can’t do it all.
Then again, we’re not very good about dealing with harsh realities. We would rather pretend they don’t exist while people suffer for lack of basic care, as long as we get whatever we need.
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I don’t like HR3200, but it won’t mean rationed care, just rationed reimbursement. We’ll still be free to pay (or rely on charities to pay) for additional care like we already do when insurance companies don’t pay.
Of course, banning private payment (Canada) would indeed mean rationed care, but I doubt SCOTUS would allow such a law to stand long.
Interesting.
You talk about policy, but don’t even consider the possibility that the government shouldn’t be involved in this at all.
Try this one for size: instead of the government tell people what they can or cannot have when it comes to healthcare, what would the situation be if the government wasn’t involved? What if people had to turn to themselves, charities, friends, families, and private enterprise for their healthcare?
I know. You’re a product of NY and it’s 100% government run healthcare industry and can’t begin to imagine such a concept. But try, and see what you come up with. You might be surprised.
> As President Obama’s health care plan is considered, one point of debate looms large. Should health care be rationed?
The premise underlying this question, as it has been very deliberately phrased, is that the current American health care system does not ration care.
Whereas nothing could be further than the truth.
There are two gatekeepers limiting access to health care in America. The first is insurance companies: their fiduciary responsibility, as they see it, is to deny care to as many patients as possible to maximize their profits. Gee, that sounds an awful lot like rationing to me.
The second gatekeeper is ability-to-pay. If you are uninsured or underinsured, the factor that determines whether or not you receive care is whether or not you can pay your medical bills. The flip side of this coin is that your ability to receive the most timely medical care is based on your ability to pay extra to jump the line.
There are a limited number of doctors and facilities in any health care system; this isn’t a problem unique to America.
Remember how they used to handle “rationing” on M*A*S*H? They called it triage (from the French word for “sorting”): the most critical patients received care first. (Can you imagine running an army field hospital on the basis of offering first treatment to those with the best insurance or the ability to pay?)
The concept of triage underpins most functional health care systems. In the UK and in Canada, countries with medicare-for-all health systems, if you need care urgently, triage puts you to the front of the line. If your condition is not life-threatening, you may have to wait while someone’s life is saved.
My point: the question of “rationing” as it is being bandied about in the health care debate is a deliberate red herring. (And I’m sure the emotional term “rationing” is being used over the more accurate term of “prioritizing” because it was focus group tested by a marketing firm, possibly by Frank Luntz).
Given that prioritizing the allocation of limited resources is inevitable, the real question becomes: What kind of health care “rationing” (sic) do you want?
You can keep a system that prioritizes care based on profitability and ability to pay; or, you can reform to a system that prioritizes are based on urgency of treatment. It’s your call.
(Here’s a hint: drop the focus-group language like “rationing,” and you’re more likely to make a more rational, less fear-based decisions.)
I know what I pick: if triage was good enough for Hawkeye Pierce, it’s good enough for me.
A nuanced point indeed. And that’s fine, providing that a person can pay out of pocket. There’s no reason in the world why they shouldn’t be able to obtain any treatment they desire, provided they can afford it. By the way, my point wasn’t in reference to the bill, but the concept. People hate the idea of rationing health care, but also hate paying for health insurance, and also hate denials of heroic measures. The numbers don’t add up.
Thanks for adding the simple view, but this isn’t about government run health care. It would be true whether government or private.
Private insurers don’t ration, but rather work on a profit motive. To put it otherwise, they ration for their own benefit, not society’s. Similarly, ability to pay isn’t a choice, but the absence of choice. True that it may end up in the same place as rationing, but rationing is, as you later note, triage in one respect and the basic allocation of scarce resources in another.
The decision to ration health care funds must be done in the public interest, rather than to further private profts or to keep the poor out of nice hospitals. This discussion can’t happen until there is consensus that its the best solution for society as a whole, though not necessarily for particular individuals from time to time.
Why not ration legal representation as well? How much time and effort is spent on a single murder case, regardless of likelyhood of the outcomes, when those same resources could be used to represent dozens (hundreds?) of misdemeanor offenses?
Not everyone will be aquitted. What is the logic of wasting highly specialized professional legal services on cases that have a foregone conclusion?
I really feel for the indigent man who kills a police officer in a SWAT raid when the police had the wrong house. However, there are many others forced to pay traffic fines when they were caught in nothing more than speed traps meant to generate revenue.
I’m not trying to make a false analogy here but the parallels are incredible.
Perhaps we should ask ourselves before rationing healthcare, would society be better served by rationing legal services that may be used in healthcare cases? How many more people would be saved by limiting the awards given plantifs in healthcare cases and placing a cap on what their legal represtatives may make?
I don’t want to mix comments to your posts, Scott, but this also draws a lot of parallels to “Can You Hear Me Now?”.
We make a lot of “sacrifices” in voice quality to provide a larger coverage area. Even landlines have made sacrifices in voice quality so that they may be provided at a lower cost to a greater number. There are measurements used to guage voice quality in wireless communications (no cool names, many are just alpha-numeric). One with a name though is an “Erlang”. By reducing the number of erlangs, voice quality can usually be increased.
Many people do not care if others ten miles out of the city are unable to get a wireless call just as long as their call isn’t dropped when they get in an elevator.
What the operators do in this case, though it costs consumers more, is build their infrastructure. The net result is ever increasing voice quality and coverage area.
You’re absolutely right about the parallels. One death penalty case sucks up the resources that could cover hundreds of other felony cases and perhaps thousands of misdemeanors. I’m not sure that we can discern outcome of prosecutions in a triage type review as well as medicine, but your point is well taken. Of course, this reflects not merely the cost of defense, but of police investigation, scientific testing, expert witnesses, prosecutorial resources as well.
Take the JonBenet Ramsey case, for example. The investigative and expert resources used in that case were massive, and could have been well applied to many crime that were never investigated. Those same funds could have been used to investigate the thousands of missing children whose faces appear on milk cartons, but aren’t nearly as photogenic as poor JonBenet. Yet each child is equally precious.
And your analogy to cellphones is similarly apt. We engage in a cost/benefit analysis in almost every aspect of life, with the occasional off-the-charts deviation that wholly ignores the analysis based upon some sentimentalism or absolutist vision of a perfect society. But the fact remains that the vast majority of the time, we trade off “perfection” for cost.
These are the normative (value judgment) calls made regularly, but few want to admit that the decision is based on one person’s/one side’s view of what matter and when. Because most people aren’t ready to face up to the limitations demanded by the allocation of scare resources, we pretend that there is a rational basis for distinguishing one case from another, resulting in individuals making these decisions for society, rather than have a larger discussion of what we, as a society, value sufficiently to be worthy of greater resource.
And then some people are just too damn stupid to realize that the allocation of resources is a value judgment, believing that whatever matters most to them is, in fact, rationally justified rather than simply their choice of how to allocate resources. This includes many decision makers. We see this all the time when people fall back on “common sense” as a rationale, assuming that common sense is a constant rather than each individual’s version of what’s normal and obvious to them.
Great points, Shawn.
By you’re own writing you only show the government point of view, and don’t go near private solutions. You see one “policy” for “the greater good” and throughout your post talk about government programs, health insurance (As dictated by the government. Find me one health insurance policy that is NOT dictated/manipulated by a government), and rationing. These are all associated with government legislation; not potential private solutions like I list in my older post.
It’s actually your view that is the simplistic one. You assume from the outset that healthcare must be managed by the government. Once your “Mommy Government” is out of the picture the question of policy goes right with it, and the picture becomes extremely more complicated. No longer would there be one “policy” as you write above; there would be a viewpoint and solution for every individual situation. You would see that if you got out of NYC more often.
I get the impression you can’t see past a government policy “for the good of society” as its enforced by the barrel of a gun (As all government policies ultimately are). Can you even conceive of the rationing being done on an individual basis by individuals? Are you so seeped in the NY socialist health care system that the idea of individuals making choices on their own with the resources they can draw upon themselves can’t fire a single synapse? It happens every day, and you wouldn’t even have to leave the state to find it.
Get out of Manhattan and spend some quality time with people in New York that live west of the Hudson and see how they make do with what they have available to them. Maybe then you’ll see that your simplistic view isn’t going to work, while my more complicated view has better odds at helping more people with the resources at hand.
Sigh. I’m not showing anybody’s point of view, nor does my post suggest that the I favor the government’s plan in any way. Rather, I’m discussing one aspect of the proposal under debate. You’re proposal isn’t under debate, no matter how much you believe that you’ve got the solution. Unfortunately for you, no one agrees with you that a pure private system is the answer to health care. Not in New York, or anywhere else for that matter.
Reasonable people understand that a pure private system would leave people who can’t afford medical care or health insurance dying in the streets. There would be no “viewpoint and solution for every individual situation” (whatever that is supposed to mean), but a cash and carry system of medicine. If you have the cash, then you receive treatment. If not, then you suffer. This is a great nation, and most people believe that we need not have people dying in the streets to promote fringe political ideas. Even rugged individualists don’t want to step over the dead bodies of the poor littering the sidewalks. The odor alone would make the walk unpleasant, and might possibly soil their designer shoes.
But that’s not the subject of this post.
To boot, your attempt to characterize me as a Manhattan elistist is simply wrong, and what you’re unlikely to realize, since you aren’t a regular reader, is that the only person impugned by your silliness is you. I realize that you’re busily trolling the internet to find people who disagree with your take on health care and teach them why you’re right and everyone else in America is wrong, but you really aren’t very good at it. Perhaps you should consider the possibility that you aren’t entitled to assume whatever you find convenient to support your bizarre views. But whatever you do, do it elsewhere. Perhaps someplace where fruitcakes are welcome?
“fruitcake”? You’re sinking to his level. It’s your blog, you don’t have to put up with commenters that rudely characterize you or continuously bend the discussion off-topic.
You’re post was about how we must find a way to limit resources to maintain a level of availability for every citizen, not a greater discussion of private solutions. That’s a fine discussion to have, but you don’t have to host it in your comments section.
I have a general aversion to absolutist, strident, nonsensical political extremists showing up here for a single post and behaving like a jerk. Sometimes I will just delete comments, and sometimes I will use them to point out that they reflect a ridiculous point of view. I think fruitcake was relatively restrained. I’ve said worse.
As for allowing the discussion in the comments, rather than just tossing it, I’m reluctant to give in to the impulse to censor comments, even those that are off-topic. Most of the time, this is how I deal with them. It’s just my way. Your mileage may vary.
So according to you if someone needs a biopsy of the lungs but someone needs a heart transplant the heart transplant patient gets first dibs, meanwhile the biopsy patient develops full blown pneumonia and falls into a comma, which a simple biopsy would have detected and later has to be put on a ventilation machine that in the end the family pulls the plug on the biopsy patient and the patient dies.
Also and meanwhile back on the operating table the heart transplant patient kicks the bucket, which is what happens more often than not.
Oh yeah and what about mystery diagnosis’ what do we do with these patients just let them suffer because there is no prognosis?
How about people show a little restrain when wanting a “raise” a family and actually wait until they can afford one?
How about when people have a cough they don’t go to the E.R.?
How about when a kid falls down and scraps their knee mommy doesn’t run them to the E.R. when a $1 bottle of peroxide and ten cent band aide would have fixed?
Also to think doctors are evil and are just racking up money with CAT scan machines is about as dumb an idea as the $550 billion being proposed to purchase 5 jets.
The United States Federal Government can’t manage the programs they got and you want them to manage our health care?
Unreal.
Any brand of Socialism is an intrusion on Individual Rights.
What part of history class didn’t you get?
“The essence of freedom is the proper limitation of government” ~ Jean Cauvin
How long have you heard these voices whispering inside your head? It’s always best to argue things that people actually said rather than the things you imagine they said.