In denial

The rationing we know
The Remote Area Medical Volunteer Corps is a charitable organization that brings free health care to regions of the globe where medical care is scarce or unaffordable—such as parts of Tennessee, Kentucky, Virginia and Utah. When RAM volunteers open up one of the temporary clinics in the U.S., people line up and wait for hours—sometimes all night, sometimes in the rain—for the rare chance to see a doctor. Most of them are there because they don’t have health insurance or any means to pay for care. Some are there because the insurance they have is inadequate. “People will come in that haven’t seen a doctor in ten years,” remarked one volunteer doctor last year, who went on to comment: “It’s amazing in a country as affluent as we are [that] we can’t take care of these people.”

It is amazing that some Americans have to turn to the charity of doctors for basic care. Amazing, too, that so many commentators on health care can see groups like the RAM corps in action and still pretend that we don’t ration health care in this country. Of course we ration health care—we do it on the basis of income level. The data tell the story: 15 percent of the population is uninsured, and 24 percent say they have gone without care because of cost. The Urban Institute estimates that 22,000 Americans die each year for lack of health care.

The choice, as New York Times writer David Leonhardt puts it, “is not between rationing and not rationing. It’s between rationing well and rationing badly.” The U.S. spends twice as much of its GDP on health care as do European countries, while getting worse results, according to many indicators, and leaving millions without access to basic care. That’s rationing badly.

Yet for all the complaints about inefficiencies, excesses and inconsistencies in the health-care system, it appears from the debate in Congress that the country is still not ready to consider what rationing well might look like. A phobia about the term rationing prevents a rational discussion.

One of the chief indicators of denial is the way members of Congress run away from the idea of allowing comparative effectiveness research to govern health-care decisions. The nation is woefully lacking in studies that reveal which drugs, methods and devices are most effective for treating various illnesses. But we need such studies if we’re going to make rational decisions on how to use scarce health-care resources.

The nation cannot afford to spend unlimited amounts on everybody’s health. Trade-offs will be necessary. Eventually, for everyone to have basic health insurance, some people will probably have to have more limited health coverage than they do now. If it is limited on the basis of scientific studies of comparative effectiveness—well, that is much fairer than limiting it on the basis of income. In fact, that’s rationing well.

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