Up to now, the debate over health care has focused mostly on how to cover the insured and how to control costs by paying providers less or reimbursing them on a different basis, such as pay for value. Much less attention has been paid to the need to ration care--and for a good reason: patients are voters. Unsurprisingly, President Obama, Sen. Max Baucus, and other Democrats have disavowed the concept of rationing, while the Republicans have been doing their best to suggest that the Democratic reform plan would lead to rationing and even to euthanasia of seniors.
But as Peter Singer, a Princeton University professor of bioethics, pointed out in the New York Times Magazine a few weeks ago, every country rations care in various ways, because resources are not unlimited While some do it by queuing or restricting access to high-tech care, the U.S. system rations care by the ability to pay. The uninsured are the most affected, but privately insured Americans are also seeing their access to health care slipping away as insurance premiums, copays and deductibles skyrocket. Nevertheless, three-quarters of them are still satisfied with their health care. So, while they see problems with the overall system, they don't want to rock the boat and risk losing anything they have now.
What the politicians are afraid to tell them is that there's really no alternative to changing how we ration care in this country. If we spend $1 trillion over the next decade to cover the uninsured, but don't place limits on what patients are entitled to under some kind of standard benefit package, we'll just be putting off the inevitable adjustment we'll have to make when the government can no longer afford to subsidize insurance for the majority of people.
Kevin Pho on his KevinMD blog has it exactly right when he says that patients will have to sacrifice something, too. "Having it both ways, wanting change yet maintaining the status quo, will be close to impossible if health care costs are truly to be contained."
The question is, how do we go about building consensus for such a wrenching change that will affect every American? Steven Weinberger, MD, deputy executive VP and senior VP of the American College of Physicians, offers an interesting take on this issue. Instead of arguing about rationing, he says, we should be making sure that our healthcare resources are not misused or overused.
It's pointless to try to figure out how much a year of life is worth for purposes of defining what we should cover, Weinberger argues. It makes more sense to concentrate on eliminating services that do not provide much value, such as expensive imaging tests for low back pain. Comparative effectiveness studies could also help contain costs in a rational way. "If treatment A is shown to be better than treatment B, favoring the use of treatment A or limiting the use of treatment B is rational use of healthcare, not rationing."
Of course, the devil is in the details, Weinberger acknowledges. For example, if treatment A is much more expensive than treatment B but is slightly more effective, our decision makers would face an ethical dilemma.
I'd add one element to this discussion that was suggested many years ago by technology assessment and guidelines expert David Eddy, MD. If we set up a national body of experts to determine what belongs in a standard benefit package, that entity should include an advisory council of non-expert citizens who have moderate incomes. When presented with the alternatives in clear laymen's terms, including the amount that a particular treatment or technology would add to their premiums and taxes, this council could make an invaluable contribution on matters related to patient values and expensive technologies that our country cannot afford.