A Rational Look At Rationing
If I were giving members of Congress a homework packet on health reform, David Leonhardt's column on rationing would be at the front of it. There'd be a worksheet on it. And, when they got back to their desks, a quiz. It's important.
"The case against rationing isn’t really a substantive argument," writes Leonhardt. "It’s a clever set of buzzwords that tries to hide the fact that societies must make choices." I'll let Leonhardt explain that to you. I want to focus on his conclusion. "The choice isn’t between rationing and not rationing," he says. "It’s between rationing well and rationing badly."
One way of explaining why health care in America is so expensive is that we pay a very large premium in order to be passive. Rationing, as Leonhardt says, involves making choices. We spend a lot of money to avoid making those choices.
A good example came in the interview Barack Obama gave to, well, David Leonhardt. Obama's grandmother had been diagnosed with terminal cancer. She was given no more than a few months to live. A few weeks after that diagnosis, she fell and broke her hip. The doctor said that the operation to replace her hip might be too much for her heart. It might kill her. But without that operation, her quality of life in these final few months would be very low.
She elected to get the hip replacement. Medicare -- that is to say, the taxpayer -- provided it. Two weeks later, she died. You can argue whether the operation was worth it. But at the time, there was no argument. She made the decision and our taxes paid for her care. However many of those types of treatments we, as a society, would choose not to pay for if we had to make the choice, add up their total cost and you have the premium we pay for passivity. It's not money in order to say "yes" so much as money we spent in order to avoid the possibility of having to say "no."
Want another example? Turn your attention to the dread "waiting lines." A 2001 survey by the policy journal Health Affairs found that 38 percent of Britons and 27 percent of Canadians reported waiting four months or more for elective surgery. Among Americans, that number was only 5 percent. This, Americans will tell you, is the true measure of our system's performance. We have our problems. But at least we don't sit in some European purgatory languishing without our treatments.
There is, however, a flip side to that. The very same survey also looked at cost problems among residents of different countries: 24 percent of Americans reported that they did not get medical care because of cost. Twenty-six percent said they didn't fill a prescription. And 22 percent said they didn't get a test or treatment. In Britain and Canada, only about 6 percent of respondents reported that costs had limited their access to care.
The numbers are almost mirror images of each other. Twenty-seven percent of Canadians wait more than four months for treatment, versus only four percent of Americans. Twenty-four percent of Americans can't afford medical care at all, versus only 6 percent of Canadians.
In Britain and Canada, in other words, they ration actively: The government tells you that the resources are scarce and you'll have to wait. In America, we ration passively: You can't afford the cost of care, and so you go without. But would anyone really prefer never getting care they needed to waiting four months to receive it? But rationing by income means that we don't actually have to decide that people will have to wait, or won't be able to access, care. It just sort of...happens.
But not making a choice is, when you're paying for it, a choice. We haven't explicitly "decided" to spend a fifth of our gross domestic product on a health care system that's twice as expensive as any other country's and leaves 15 percent of our population uninsured. But we've accepted it. We're paying for it.
At the end of the day, no one can argue with the fact that it's nice not to have to make decisions. But it's also expensive. And sooner or later, we're going to have to make a very big decision: Do we really think it's worth it?
(Photo credit: Damian Dovarganes - AP)
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