How Can We Deny Health Care to Poor While Others Get Face Lifts?

The American health-care system, the experts say, is going bust at a rapid rate. Efforts to contain our burgeoning $500-billion-plus tab through economic juggling and shifts to prepaid medical plans have been a total failure.

The dilemma of how to pay for health care is forcing some public officials to think the unthinkable. Alameda County and the state of Oregon recently announced plans to institute explicit rationing policies for health care.

But, before you applaud the realism, consider that these plans would ration access to health care only for the poor. The medically indigent of Alameda County and those eligible for Medicaid in Oregon will be required by law to forgo life-saving medical care. One generation’s war on poverty is becoming another’s war against the poor.

Officials in both Oregon and Alameda County note that the poor have always gotten less access to health care than the rich. This is true. But our society’s failure to meet the health-care needs of the poor hardly justifies a public policy that asks the poor to bear the burden of rationing as a matter of law.

Who concocted this blatantly unethical scheme? Incredibly, the inspiration for both the California and Oregon plans for pocketbook triage comes in part from those in my line of work--medical ethicists.

A California bioethics consulting firm is being paid by Alameda County and Oregon state officials to provide moral rationales for dropping the poor out of the health-care lifeboat. The consultants appear to be approaching their task with gusto.

“You have to draw the line somewhere,” one moralist-for-hire said in a recent newspaper article about Alameda County’s decision to begin rationing for the poor. “We’ll provide all services to a diminishing segment of the population, and literally we’ll throw the rest of the people overboard. We’re thinning the soup and lengthening the line,” he explained in language more appropriate to Scrooge than Jesus, Kant, Mill or Niebuhr.

No hint is given of the theoretical position that would justify aiming all rationing efforts at the poor. But it is hard to think of a moral or religious ethic thatholds that when a nation cannot pay its doctor bills, it is the poor and only the poor who should be denied the right to see a doctor.

It is hard to understand how any ethicist could become involved in a scheme so blatantly unfair as that of rationing necessary health care only for the poor. What is worse is that the same ethicists and the officials taking their advice, who are enthusiastically directing triage at the California and Oregon health-care lifeboats, are not asking whether it is really necessary in 1989 to institute the rationing of necessary medical care for anyone.

Before saying goodby to the indigent, why aren’t public officials in Oregon and California thinking about reforming a malpractice system that adds tens of millions of dollars to state-financed health-care costs each year? Before saying no to a bone marrow transplant for a 3-year-old whose mother is on Medicaid, couldn’t county and state legislators insist that every licensed hospital and physician be required by law to provide a fixed percentage of care for those who cannot pay?

Before creating laws that would send some of the poor to a premature demise, county and state officials ought to require private health insurers to charge subscribers an additional premium that could be used to supplement the pitifully small budgets of Medicaid and public hospitals. And would it not make some sense to insist on a luxury tax, which could be used to help meet the crucial health-care needs of the poor, from the rich who avail themselves of psychotherapy, vitamins, cosmetic surgery, diet clinics and stress-management seminars?

It is wrong to make the poor and only the poor bear the burden of rationing. It is unethical to institute rationing of necessary health services for any group of Americans unless we have made every effort to be as efficient and as frugal as we can be in spending our health-care dollars.

At a time when some can indulge their wants by buying a face lift, it seems extraordinarily hard for ethicists or legislators to convincingly argue that they have no other option but to condemn the poor to die for want of money.