Health Care Faces the 'R' Word
Even though more and more Americans have no health insurance at all, Americans consider health care to be a right. Not just that: We consider the best possible health care to be a right. Few would find it acceptable for a poor person to die of a medically curable disease for lack of money. Even fewer would find it acceptable that they themselves should die because the system won't spend the money to cure them. This is all in theory, of course. In practice, people die all the time because some effective treatment is too expensive. But whenever an issue gets drawn into the political system and becomes explicit, it becomes harder. That is what health-care reform will do to the question of rationing.
The Obama administration believes that health care can be made cheaper without any reduction in quality. It has evidence to back this up. According to the famous Dartmouth studies, health care costs two or three times as much per person in some places in America as it does in others, with no measurable difference in results. Atul Gawande's deservedly admired recent essay in the New Yorker makes a similar point. So in theory it's easy: Just figure out how the cheap places do it and apply this knowledge to bring down the cost in the pricier places.
But that doesn't mean rationing will be easy to avoid. Statistics on life expectancy or infant mortality are averages. The easiest way to raise your averages -- maybe even the best way, if we're being honest -- is to concentrate on the general level of care and not to squander a lot on long-odds cases. But if the long-odds case is you or a family member, you may well feel differently.
In the debate about how to reform health care, "how" means two different things. One is the industry structure: Should we simply nationalize the whole system or set up a government alternative to operate alongside the private one? Or are there novel market-based alternatives that ought to be tried? Gawande thinks the problem is a culture of medicine that has become too greedy. Others believe that human greed is a given and that either the government or the market will have to do a better job of controlling it. The other "how" is how the actual course of treatment for patients will change. Here there is much less to debate. Cheaper treatment means less treatment: fewer tests, fewer surgeries, fewer drugs.
Less care doesn't necessarily mean worse care. The administration is investing great hopes (and $1.1 billion of stimulus money) in "comparative effectiveness research." Because we don't collect and compare in any systematic way the vast piles of data we have about individual patients and their treatment, we know astonishingly little about which treatments work and which are a waste of money. The administration is touting the figure of 30 percent of all health-care costs as spending that may accomplish nothing.
I suspect that what a billion-plus dollars' worth of research will find is that perhaps 30 percent of what we spend on health care is almost entirely worthless, or just barely better than a much cheaper alternative. Or it might be better and no one knows for sure. Denying someone these treatments or tests is rationing.
Similarly, when fear of malpractice lawsuits leads doctors to practice "defensive medicine" -- a legitimate complaint about current arrangements -- it doesn't mean that they order worthless tests. It means they order tests with only a very long-shot chance of finding something wrong.
Here is a handy-dandy way to determine whether the failure to order some exam or treatment constitutes rationing: If the patient were the president, would he get it? If he'd get it and you wouldn't, it's rationing.
It may seem absurd to worry about whether wealthy or well-insured people get every last test and exotic or speculative treatment when millions of Americans have no health insurance and millions more have gaping holes in their coverage. But the well-insured happen to include virtually all the people making the key decisions about health-care reform -- members of Congress and their staffs, the White House staff, Washington journalists, and so on. These people's fears that they would lose the right to "choose my own doctor" (code for getting treatment with all the bells and whistles) helped kill Hillary Clinton's attempt to reform health care in the early 1990s. Fear of rationing could kill Obamacare for the same reason.
Whether or not this makes sense is a question of taste, not policy.
David Leonhardt of the New York Times recently noted that spending so much on health care squeezes out spending on other things that we might prefer, and that is a form of rationing. On the other hand, the blogger Mickey Kaus argues that it makes perfect sense for a society growing richer (as ours soon will be again, we hope) to spend a growing share of that wealth on improving our health and longevity.
That is what we do as individuals. And what better to spend your money on?