Dirty Words in Health Care Debate

Much of the noise in the health care debate revolves around two epithets the left and the right hurl at each other: 'rationing' and 'denial of care.'

Both sides have a point, sort of, but both are being more disingenuous than substantive or honest.

One of the criticisms of the current system of private insurors is that they sometimes deny payment for care. Patients who don't do well on the generic medicine, or whose disease doesn't respond to conventional treatment, naturally would like their insurance to pay for some higher-cost alternative. Insurance companies, faced with pressures to keep premiums down and profits up, naturally don't want to pay for the more expensive alternative when there are less expensive options that usually work for most patients.

People who are critical of private insurance say this amounts to insurors 'playing doctor.' Treatment decisions, they say, should be entirely made by the physician and his or her patient.

One of the criticisms of government-as-payor health care systems is that they 'ration care.' It's certainly true that most national health systems have some kind of board that reviews various treatments and practices for their cost-effectiveness, and then makes decisions about what kinds of care will be provided and what will not.

One such organization is the UK's NICE (National Institute for Health and Clincial Excellence). NICE makes judgements about the safety and efficacy of treatments, much as health specialty organizations in the US do when they issue consensus opinions or clinical practice guidelines. Unlike US organizations, however, NICE also makes value judgements about the social utility of medical treatments. Using measures like Quality Adjusted Life Years (QALY), NICE makes decisions about whether the social value of a medical procedure or treatment justifies its cost. For instance, it might be determined that knee replacement surgery for overweight elderly patients does not render sufficient improvement in overall health to justify its cost.

Opponents of health reform have made great sport of attacking NICE and QUALY lately, and on some level it's hard to argue with this. It does seem heartless to tell an elderly lady, "you're too fat for an artificial knee," or "you probably won't live long enough to justify the cost of that knee replacement." More heartless, perhaps, to tell entire groups of people such things via health policy. Far better to have a system with no rationing or denial of care.

The problem is, every health system has some kind of rationing or some form of denial of care. For example, in a pure fee-for-service model treatment goes to those who can afford it and is denied to those who can't. In the US, private insurors decide what they'll cover and what they won't. Medicare and Medicaid - government payors who are the biggest players by far in the US - certainly do deny many procedures and treatments, but there's no specified system for determining what they'll pay for and what they'll deny. The biggest difference between the US and the UK therefore isn't that the UK rations care and the US doesn't. The difference is that in the UK, they admit that they ration, and they ration according to clearly specified criteria. In the US we pretend we don't ration, and then proceed to ration according to an extremely complex, mostly opaque, multi-player process with no specified criteria and no over-arching goal or guiding principle.

In the current health care reform debate, all the parties are lying about rationing.

The Republicans say they object to changing the health care system because they don't want any rationing or denial of care. That's ludicrous. As outlined above, we are already rationing and denying care as a matter of policy.

The Democrats, meanwhile, say the new reformed health care system they're proposing won't include any rationing. This is equally ludicrous. With rising health care costs, mounting national debt, and the imminent retirement of 48 million baby boomers, there will certainly be more severe rationing in our future. Whether we want it or not, we will eventually have to make some difficult decisions on health care spending because our current muddle projects to completely bankrupt the nation within 15-25 years.

It's time for both sides to own up to the unpalatable but inescapable truth: there's no way to have a fiscally sound health care system without having some kind of rationing. Either we will reform the system and have some new system of rationing, or we will continue our current system of muddled piecemeal rationing. We need to admit this and start talking about it, so we can have an honest national debate about what kind of rationing we will have.