Wake up and embrace the concept. It’s almost here.
In truth, though Pres. Obama doesn’t want anyone to use the word, rationing is something we do all the time, with the food we buy, the vacations we take, the clothes we wear. If you can’t afford Saks you likely don’t shop there. Why should health care be any different, especially once the bill is being paid by a pool of people?
So, we want universal health care. We agree that it’s an idea whose time has not only come but is a necessity. When Wal-Mart and other companies agree, you know the time is getting closer. We already ration today, through employee-employer agreements on company policies, but in a universal health care system, rationing is a dirty word. Same for the ability to pay today, which will be inherent in any health care plan. Because the cost of covering each person’s requests when they don’t pay for the care they desire themselves is something the system will only be able to take so far. But in reality, it’s already here. It’s time everyone started acting like grown ups about it.
One problem is that we don’t take responsibility for our own preventive health behavior, thinking that if we smoke, drink too much, or eat ourselves into obesity, we still deserve the same as someone whose preventive diligence has set them on a course of health and well being. This is nonsense. It should also impact rationing, especially on elective surgery, but that’s another subject beyond getting the basics done. Something to think about, because why someone morbidly obese should get new knees because of the weight their body carries through behavior over which they can control is an issue that might make some uncomfortable, but brings the point of personal responsibility home when we’re all brought in to this together.
In the current U.S. debate over health care reform, “rationing” has become a dirty word. Meeting last month with five governors, President Obama urged them to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintons’ attempt to achieve reform. In a Wall Street Journal op-ed published at the end of last year with the headline “Obama Will Ration Your Health Care,” Sally Pipes, C.E.O. of the conservative Pacific Research Institute, described how in Britain the national health service does not pay for drugs that are regarded as not offering good value for money, and added, “Americans will not put up with such limits, nor will our elected representatives.” And the Democratic chair of the Senate Finance Committee, Senator Max Baucus, told CNSNews in April, “There is no rationing of health care at all” in the proposed reform.
Mr. Baucus sounds like a salesman.
By way of further explanation, let me add something: You don’t sell a product by ignoring the bottom line. We’ve been pretending we don’t ration, which is why Obama doesn’t want to talk about it. He isn’t very strong when it comes to taking things on head on. Like saying: We have always rationed health care, so let’s not pretend this is new. It will continue in universal health care. However, we are going to tackle this straight on, not by ignoring the reality. When you duck the tough talk out of fear, you inspire drivel like this.
The article quoted above is by Peter Singer, a professor of bioethics at Princeton University. It makes a lot of sense, though it will make some people shudder. That’s because we are a spoiled lot. Never having to face the bottom line balance sheet our country now has to pay attention to, especially as Americans scream for a health care safety net for all.
The point is to give the uninsured a lifeline of sorts, bringing the egalitarian nature of our country into practice all the way down the line.
But even in emergency rooms, people without health insurance may receive less health care than those with insurance. Joseph Doyle, a professor of economics at the Sloan School of Management at M.I.T., studied the records of people in Wisconsin who were injured in severe automobile accidents and had no choice but to go to the hospital. He estimated that those who had no health insurance received 20 percent less care and had a death rate 37 percent higher than those with health insurance. This difference held up even when those without health insurance were compared with those without automobile insurance, and with those on Medicaid — groups with whom they share some characteristics that might affect treatment. The lack of insurance seems to be what caused the greater number of deaths.
So, how should this work?
But many countries combine free national health insurance with optional private insurance. Australia, where I’ve spent most of my life and raised a family, is one. The U.S. could do something similar. This would mean extending Medicare to the entire population, irrespective of age, but without Medicare’s current policy that allows doctors wide latitude in prescribing treatments for eligible patients. Instead, Medicare for All, as we might call it, should refuse to pay where the cost per QALY is extremely high. (On the other hand, Medicare for All would not require more than a token copayment for drugs that are cost-effective.) The extension of Medicare could be financed by a small income-tax levy, for those who pay income tax — in Australia the levy is 1.5 percent of taxable income. (There’s an extra 1 percent surcharge for those with high incomes and no private insurance. Those who earn too little to pay income tax would be carried at no cost to themselves.) Those who want to be sure of receiving every treatment that their own privately chosen physicians recommend, regardless of cost, would be free to opt out of Medicare for All as long as they can demonstrate that they have sufficient private health insurance to avoid becoming a burden on the community if they fall ill. Alternatively, they might remain in Medicare for All but take out supplementary insurance for health care that Medicare for All does not cover. Every American will have a right to a good standard of health care, but no one will have a right to unrationed health care. Those who opt for unrationed health care will know exactly how much it costs them.
The success is predicated on Americans becoming soberly grown up about paying for health care at every turn. Not just assuming entitlement for the best and any health care demanded, simply because that’s what Americans deserve.
We’ve entered a new era as the 21st century dawns. One in which America’s continued prowess will depend on our ability to look at the bottom line and balance it. But also look at how we’re living and the responsibility we have to modify and change the way we go about our lives.
The day of the spoiled American living off credit and a smorgasbord of choices is being down sized. How creatively we react to putting our nationalistic egos second to productive solutions all the way down the line will determine whether we rise to the challenge or fall.
This post has been updated.
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