Take Your Own Pulse

A great article by Uwe Reinhardt on what it means when the word "rationing" is used in health care. We who have insurance fail to recognize the "rationing" instituted by the health insurance company when they deny our claims, force us to pay co-pays, tier our prescriptions, etc, but we get awfully upset when the government suggests that it will not pay for certain tests, procedures, or medications that have not been shown to be effective. If you want an unproven test or procedure, and you can pay for it or get your insurance to pay for it, and you can find a doctor to give it to you, fine. But why should the government pay for your unnecessary back MRI any more than your private insurance pay for your elective breast enlargement?

What we will essentially move towards is a multi-tiered health system, where there is a basic level of care at the government/public plan level and tiers above paid for by private insurance or, ultimately, cash. Some people think this is wrong, but some of those people forget (or choose to ignore) the fact that our system now is not exactly a level playing field. We already have multi-tiered care in this country, we just prefer not to think of it that way. If my insurance covers the back MRI, or a screening coronary calcium scan (despite the fact that routine coronary screening is not indicated), then I will demand it and insist that if I don't get it I'm being rationed. Many of the people I hear using the "R" word in vain have good, comfortable insurance (and many have the cash to cover if their insurance didn't provide them what they wanted), so even if the evil of government rationing came to pass they would be largely unaffected.

While I think there are worthy arguments against cost comparisons, and I'm all for constructive debates on these subjects, I am not personally opposed to rational rationing of care. We cannot continue to have our cake and eat it too: have the most expensive healthcare for ME while denying it to YOU because your small business employer does not pay for insurance and you cannot afford a private plan. I get all the back MRI's I want while you cannot afford blood pressure medication.

Besides, something good that could come out of doing effectiveness research would be finding out when too much care is not actually a good thing. Getting doctors and patients to buy into this idea will take a lot of convincing, but if the evidence is good I think it can happen.