Should Healthcare Be Rationed?

Philip Caper, M.D.

Opponents of universal healthcare often claim that in order to afford it we will have to ration healthcare. My response to that old shibboleth is that we already pay more than enough to cover everybody, and that we already ration healthcare, as we must in a world of finite financial and real resources. The real question is not “should we ration healthcare?” but rather “What’s the fairest way to do it? 

In all other wealthy countries, where everybody has a right to healthcare, rationing is done on the basis of medical need. The more urgent the need the sooner care is provided. Urgent care is provided promptly, and less urgent care may be put off for awhile.

In many cases, delaying care for awhile is actually a good thing. There is a growing recognition that in the U.S. some types of care are too accessible, resulting in costly and risky overuse of many tests and treatments that have little or no value, and others that may actually do more harm than good.  

In exchange for restricting access to some tests or treatments of little or no value, we could reduce overall healthcare costs significantly and largely eliminate cost as a factor in deciding who receives medical care and what kind of care they receive. In most other wealthy countries the ability to pay does not enter into the thinking of either the patient or the doctor.

The U.S. is unique among wealthy countries in using ability to pay as a means of rationing medical care. The results are often devastating. A recent Commonwealth Fund study found that in states where the number of uninsured is highest, rates of deaths from treatable illnesses are also highest. Another recent study in Massachusetts concluded that morbidity and mortality from treatable illness declined significantly after 2006, when healthcare reform expanded coverage there. 

I’m in favor of expanding healthcare coverage to everybody and rationing through overall budgetary constraints rather than simply pricing some people out of the system. While some with good coverage receive too much medical care, others without coverage receive too little and may wait forever for needed care. 

People who face financial barriers to accessing healthcare often put off beneficial primary care, only to later require care for more serious and expensive illness. Those costs end up being paid by all the rest of us.

 Medical tests, procedures and treatments have their benefits, but they also have their downsides. Drugs have side-effects, tests and procedures have risks, and all have economic costs. If we agree to limit access to ineffective, marginally effective or downright harmful care we could more than afford to expand access to everybody.

In many instances, our aggressive anything-goes style of medicine has come to cause more harm than good. Mammography and PSA tests for prostate cancer are recent examples. Over 65 medical specialty societies have each recently identified at least 5 such tests or procedures.

According to a recent study by the Institute of Medicine, we waste over $340 billion a year on unnecessary and inefficiently delivered services. That’s more than enough to extend coverage to everybody.

I believe most Americans would willingly give up something they may want but don’t really urgently need if it meant a neighbor who needed it more could have it instead. I’ve seen that happen many times here in Maine. But we seem to have a lot of trouble turning our generous neighborly spirit into pubic policy.

So why don’t we make our means-tested system of rationing more rational, and - like other wealthy countries - base it on medical need rather than financial means? Not only would our healthcare system become less costly and more efficient as a result, but it would also become more humane.

Such a change would allow doctors to treat patients the way our training and professional ethics encourage and our Hippocratic Oath demands. 

And it would make our country yet a better place to live.

Reprinted with permission of the Bangor Daily News, where it appeared on May 16, 2014.

One-liner: The U.S. has long rationed health care on the basis of ability to pay, not medical need as is done in almost all advanced countries around the world. 

Abstract: Our means-tested system of rationing health care is unfair, inhumane, and leads to many sick patients delaying or foregoing necessary health care with often preventable worse outcomes of care. Our system could save money, cover all Americans for comprehensive care, and achieve better outcomes of care if we would shift to a sytem that rations care based on medical need and eliminates some $340 billion a year in unnecessary and inappropriate care.