Science / Medicine : ON MEDICINE : As Health Care Costs Rise, Can Rationing Be Far Behind?
“Is rationing inevitable?” an editorial in the New England Journal of Medicine asked in June.
With national health care expenditures increasing at double-digit rates, many observers believe that such radical corrective measures as health care rationing will be necessary.
But although rationing might succeed in reining in runaway health care costs, it might also lead to discrimination against the elderly, the poor, the disabled and other vulnerable groups. And it likely faces a hostile reception from physicians, some of whom already believe that health insurance restrictions interfere with good patient care.
The term “rationing” is used in a variety of senses. Not surprisingly, it is widely misunderstood.
Health care in the United States has always been rationed--on the basis of price. The poor and the uninsured face significant barriers to adequate medical care, particularly if they require surgery or expensive treatments.
Health care is also increasingly rationed on the basis of health insurance: Health maintenance organization members must see HMO physicians, or pay out of their pockets. An increasing number of physicians and hospitals shun Medi-Cal patients. Insurance programs that require advance approval for surgeries and hospitalizations also limit the availability of medical care.
But current debate centers on a more far-reaching concept, known as non-price rationing. Put simply, this means that everyone’s access to some expensive treatments, perhaps some types of organ transplantation, would be limited, regardless of insurance or the potential benefits of the treatments to some patients.
If health care were rationed, some resources would be diverted from expensive therapies that may benefit a very few to less expensive tests or therapies of proven effectiveness that may benefit large numbers of people. The less expensive measures might include simple cancer screening tests, childhood immunizations and easy access to primary-care physicians.
Non-price rationing runs counter to what many consider the strengths of the American health care system. The wealthy and the well-insured usually expect access to the latest--and often the most expensive--new technologies and treatments. They also expect the ability to choose their physicians and hospitals.
On the other hand, some argue that non-price rationing might restore a sense of balance to a system run amok. While infant mortality increases in some areas of the country and a largely preventable measles epidemic remain out of control, some are fascinated by the prospect that highly experimental growth hormone treatments, which would cost more than $10,000 a year, might represent a fountain of youth for some elderly individuals.
Proposed reforms in Oregon’s Medicaid program are often cited as a model for what a rationed health care system might look like. Under a plan approved by the state Legislature in 1988, the Oregon Health Services Commission is ranking medical services on the basis of their cost-effectiveness.
The Oregon proposal would limit benefits to those that rank highest. The Legislature would determine how far down the list to go in funding services. On a preliminary ranking list released in May, treatments of a variety of serious infections, such as spinal meningitis, tended to rank highest. Varicose vein treatment and sex-change operations were near the bottom of the list.
The ranking is expected to be completed by the end of the year. But the plan still has not received federal approval, without which it cannot be implemented.
Advocates of the Oregon plan say it would benefit many currently uninsured individuals. The savings achieved by these limiting benefits would be used to substantially increase the number of state residents eligible for Medicaid.
But some health care experts believe the Oregon plan is inherently discriminatory. The proposal would primarily restrict services to the non-elderly poor in the Medicaid program, not the hundreds of thousands of Oregon residents with private health insurance or Medicare.
The Oregon plan also does not address the more fundamental problems contributing to America’s health care crisis, such as increasing costs and excessive use of technology. In Colorado, a similar proposal died in the state Legislature earlier this year.
If health care costs continue to rise unabated, a number of new rationing proposals are likely in the years ahead. One of the key unanswered questions is how physicians will react.
Not surprisingly, non-price rationing is anathema to many physicians, who believe their primary responsibility is to do their best for individual patients. On the other hand, physicians often order unnecessary tests and treatments, which contribute to increased health care costs.
Some doubt that changes in physician behavior and other reforms will be sufficient to avoid rationing. Others, such as Dr. Arnold S. Relman, the editor of the New England Journal, still believe that physicians can work with government to avoid rationing while providing “an acceptable standard of care for all Americans.”
This question will be answered in the years ahead. Says Relman, “By the turn of the century (physicians) shall either have helped the United States to improve its health care system substantially or we shall find our services to patients externally regulated and rationed as never before.”
