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We Ration. We Ration. We Ration. We Ration.

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"Look at Canada," says Charles Krauthammer. "Look at Britain. They got hooked; now they ration. So will we."

So do we. This is not an arguable proposition. It is not a difference of opinion, or a conversation about semantics. We ration. We ration without discussion, remorse or concern. We ration health care the way we ration other goods: We make it too expensive for everyone to afford.

I've used these numbers before, but let's repeat them. 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. That's rationing.

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. And the American numbers are understated because if you can't afford your first appointment, you never learn you couldn't afford the medicine or test that the doctor would have prescribed.

We ration. And if the numbers and the surveys don't convince you of the point, this is what it looks like when we ration.

Photo credit: By Elise Amendola — Associated Press

By Ezra Klein  |  August 28, 2009; 12:45 PM ET
Categories:  Health Reform  
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Comments

This should really be reported as:
27 percent of Canadians waited more than four months for surgery, 6 percent waited forever.
5 percent of Americans waited more than four months, 24 percent waited forever.
Which would you prefer?
(Also note that it's worse than that- the first number is for elective surgery only, the second if for all health care, elective or not. Do you have the waiting times and permanent denial rates in Canada, UK, and US for essential surgeries?)

Posted by: _SP_ | August 28, 2009 12:57 PM | Report abuse

Based on that last link, are you saying that Obama's plan will include dental and vision coverage?

Posted by: tomtildrum | August 28, 2009 12:57 PM | Report abuse

It's critical to point out that those numbers are the inverse of each other, as CANADA AND BRITAIN SPEND HALF OF WHAT WE DO.

If Canada and Britain spent what we spend, there would be no lines. None at all.

So, why do we have lines? Why do we have people suffering because they are standing outside on line, locked out of care?

Canada and England have lines because they're cheap bastards. We aren't cheap bastards. So why is everyone still on line?

Posted by: theorajones1 | August 28, 2009 1:17 PM | Report abuse

i'm curious as to what the wait times are like in MA. where we have near universality which is one of the goals of reform and no government run plan? I'm sure Ezra has commented on it before, no?

Posted by: visionbrkr | August 28, 2009 1:17 PM | Report abuse

What don't you get about this not being the American way? You want 75% of Americans not being rationed to take up rationing to get the rest to the doctors; yeah fat chance of that ever happening.

If we were talking about cars what you would be asking is for people with BMWs and Porches to trade them in for a Ford Focus so everyone can have a Focus.

No one wants to dumb down their own care to bring up someone else’s care. Until you can insure the uninsured without taxing the limited resources the majority will not go over on this issue.

Posted by: flonzy3 | August 28, 2009 1:31 PM | Report abuse

flonzy3,

While I liked most of your points, I didn't like the, "What don't you get about this not being the American way?"

Why must everyone define their side as the patriotic, American side? No one died and appointed you judge of what is the offical American way.

Posted by: niceshoes1 | August 28, 2009 1:36 PM | Report abuse

flonzy3,

forgetting about the human aspect of it though they are costing us more and it could save money if everyone was covered. That's why i liked one of the original ideas of President Obama of community health clinics. Those of us with insurance have premiums that go up because people aren't getting care they need to diagnose a problem before it becomes an expensive one. I'd like to think if i had cancer for example that I would forgo 3-4 catscans or MRI's per year in favor of 1-2 so that an uninsured person could get a preventative screening so that they catch their problem earlier and not only help them but cost the system less. Then we all benefit. But until we're put in that position who knows how we'd react similar to the end of life care concerns. To that end I don't know why Medicare only allows one preventative screening when you join up and not annual ones. I hope that correction is included in the legislation whenever it passes.

Posted by: visionbrkr | August 28, 2009 1:44 PM | Report abuse

I've never understood why this "rationing" argument has any traction at all. Everything that is not infinite, by definition, is rationed.

Posted by: itch | August 28, 2009 1:46 PM | Report abuse

Ezra- would you say that we ration cars in the US? I think that you have a very odd definition of rationing when you think that just by putting a price on something you consider it to be rationing.

Posted by: spotatl | August 28, 2009 1:49 PM | Report abuse

And Ezra, it's important to note that rationing does not occur in our system just with the uninsured.

Health Insurance companies deny many treatments.

Here's Dr. Sanjay Gupta of CNN on this:

People always say, is there going to be rationed care? And I can tell you, as a practicing physician, as someone who deals with this on a daily basis, rationing does occur all the time. I mean, I was in the clinic this past week, and in the clinic I get all of this paper work that basically says, justify why you're doing such and such procedure, justify why you're ordering such and such test. And if the justification is inadequate, the answer comes back, well, that's not going to be covered. Which basically is saying that the patient's going to have to pay for it on their own. Which is, in essence, is what rationing is, in so many ways. So it does occur, much to your point, Anderson. [Anderson Cooper 360, 08/12/09, at: http://mediamatters.org/mmtv/200908130010]

Moreover, people with health insurance also commonly ration their health care due to high deductibles and co-pays, and hitting their insurers' lifetime limits.

Posted by: RichardHSerlin | August 28, 2009 1:49 PM | Report abuse

Sigh. Will the lying about how things are ALREADY rationed never stop? As a previous poster said, putting a price tag on something is not rationing. You, the consumer, can decide to go broke to buy that thing if it's expensive and you really want it. You can earn more money. You can beg and borrow. Rationing occurs when, and only when, the provider will not supply it for love or money.

Posted by: truck1 | August 28, 2009 2:02 PM | Report abuse

@spotatl

Rationing by price is still rationing just like rationing by need is (even though no program currently being considered has rationing by need.) Just because a service is available doesn't mean I can access it. That is rationing, allocating a limited supply of healthcare to those who can pay the most for it. The question is, "Is rationing by price the most effective way to get healthcare to those who need it?" My answer is no.

We ration cars by price. If I don't have the money to buy a car, I don't get one, even if I need one to get to work.

What part of this don't you understand?

Posted by: srw3 | August 28, 2009 2:08 PM | Report abuse

@flonzy3

You want 75% of Americans not being rationed...

Everyone with insurance has rationed care, determined by what your insurance will cover and what it will not cover. Currently, yearly and lifetime caps on care is rationing. I can't get unlimited health care from my insurer. My insurer rations my care, allowing me access to some services and not others. That is rationing, mostly by price (to the insurer, in this case.)

Posted by: srw3 | August 28, 2009 2:12 PM | Report abuse

Adding to my last comment, here is a quote from a 1995 Journal of Political Economy article, by University of Chicago economist John Cochrane (somewhat ironic because he appears to be pretty libertarian in other writings), "Time-Consistent Health Insurance":

Currently available health insurance contracts do not fully insure many long-term illnesses, such as AIDS, cancer, senile dementia, heart disease, or organ failure. Many people who get such diseases face ruinous increases in premiums. Others lose their health insurance by losing their job or their spouse or by exceeding a lifetime cap on benefits. Some are bankrupted by health expenses; some are unable to get further medical care. (page 445, at: http://www.jstor.org/pss/2138695)

This is another very big and tragic way that those who have insurance nonetheless experience rationing.

Posted by: RichardHSerlin | August 28, 2009 2:16 PM | Report abuse

srw- do you think that we ration cars in the US? I just think its a misuse of the term.

And I say this as someone who's main concern with goverment healthcare is that there won't be sufficient rationing and the price will skyrocket.

Posted by: spotatl | August 28, 2009 2:23 PM | Report abuse

Richard,

While Dr Gupta is right that insurers do that if there wasn't fraud and abuse of the system by all then insurers wouldn't have to be the "bad guy" when it comes to that. I'm not saying Dr Gupta is abusive as I'm sure he's not. I've stated this example before but I'll do it again. Physical therapy is a widely abused part of insurance. So much so that insurers had to cap the level of benefit to curb abuses as people were getting physical therapy forever and racking up bills for insurers (which in turn increased costs and rates) and profits for physical therapists. I'm no doctor but I would think that after a couple years if physical therapy isn't working something else should be tried, no?

I had a client who went to physical therapy after a shoulder injury. She went for about 5 months when her insurance was about to be capped at the 30 visit limit that it had. The patient called me and said can we have it adjusted. She said that the physical therapist said that they had about another 5-6 visits left and that they could space it and make it about 1 visit per week so it would last longer for her. Maybe once every other week but she still needed a bit more to carry her through the year. Their plan was a partially self insured plan so there are provisions where it can be done outside the terms of the insurance contract if the employer allows it and the company just picks up the tab. This woman was the owner's mother so they wanted to pay for it. We made sure it was covered for her and then low and behold when the physical therapist got wind of it they started treating her at 3x per week again with no explanation.

Eventually the owner's mother caught on that it wasn't helping her necessarily, just helping the doctor's bottom line. She stopped going and she's fine today.

If there were more doctors like Dr Gupta and less like the physical therapist who will remain nameless then insurers wouldn't have to ration certain benefits.

Posted by: visionbrkr | August 28, 2009 2:25 PM | Report abuse

srw3:

"We ration cars by price. If I don't have the money to buy a car, I don't get one, even if I need one to get to work.

What part of this don't you understand?"

Ok, so then there's no way that Obama's plan rations at all by your definition. It never says you can't pay out of your own pocket for any treatment you want. It just makes treatments more affordable, a lot more affordable for most families, a lot more affordable than with the current system.

Posted by: RichardHSerlin | August 28, 2009 2:27 PM | Report abuse

@spotatl

I don't think that I am misusing rationing, which is just another word for allocating and we do allocate health care based on the ability to pay.

Posted by: srw3 | August 28, 2009 2:32 PM | Report abuse

RIchard,

up until very recently Memorial Sloan Kettering in NYC only accepted Medicare and Blue Cross. That's it. So in people's whose plans don't cover services out of network their care is being rationed no? HOw is that the insurers fault?

Should they outlaw HMO's?

Should out of network provisions allow for whatever cost a doctor wants to charge? $100,000 for a 5 minute office visit OK with you? How much is enough?


They face ruinous increases in premium because the costs are warranting it. Part of this legislation will take away the insurers profit with a required 85% loss ratio but when costs continue to rise as they will what to do then? Its not as if countries with socialized medicine aren't facing cost increases. They just account for it in higher tax rates or decisions based upon an age, condition factor that determine if you get care or not (Britian's model)

Posted by: visionbrkr | August 28, 2009 2:34 PM | Report abuse

srw- do you think we ration gasoline in the US? I live in Atlanta- I got to see what Gasoline rationing actually meant when the hurricane hit. If you think that we currently ration Gasoline in the US simply because there is a price set on it and some people cannot afford as much of it as they would like I simply think you are using the term incorrectly.

Posted by: spotatl | August 28, 2009 2:35 PM | Report abuse

Well if you define rationing as anything other than someone getting all they want when they want, yeah we ration care. And everything else in America.

Not being able to afford something or all you want of something is not rationing, it's life. Healthcare is a commodity like anything else, some people can afford all they want or need and some people can't. Just because your plan doesn't cover everything you need or has caps just means that's the coverage you bought; there are other plans out there that do what you want but just because you can't have them doesn't mean they're rationed.

America does our healthcare this way so therefore it's the American way by definition.

Posted by: ronjaboy | August 28, 2009 2:37 PM | Report abuse

visionbrkr's blaming dumb patients and greedy doctors again? What a surprise.

Posted by: pseudonymousinnc | August 28, 2009 2:38 PM | Report abuse

@RichardHSerlin

Right. Obama's plan does make healthcare more affordable, but it doesn't change the underlying model, which is you get the healthcare you can afford, with or without insurance.

Posted by: srw3 | August 28, 2009 2:39 PM | Report abuse

It's specious to compare health care insurance to buying cars. There are certain basic rights a civilized society recognizes and access to medical care should be one. Rationing has a role to play in ensuring cost-effective treatments and a sane discussion on how limited resources are allocated. I think insurance plans should cover preventative and good outcome based treatment, but keeping people alive in a vegetative state should be an out-of-pocket expense (a choice not borne by other premium payers). That is rationing.

Posted by: phsato | August 28, 2009 2:41 PM | Report abuse

"Healthcare is a commodity like anything else"

That's the spirit! Your kind of thinking's just what's needed to send America straight down the toilet.

Anyone else got a different way to say "screw you, I got mine"? There seem to be so many variations.

Posted by: pseudonymousinnc | August 28, 2009 2:41 PM | Report abuse

pseudo,

hi! So do you claim that doesn't exist? Patients don't understand abuse of the system (my client did) and doctors don't abuse the system??


pseudo isn't telling us what he does, isn't THAT a surprise. Which are you patient or doctor or both???

I've admitted insurers are wrong for plenty they do. Why won't you admit WHAT you do? If you don't honestly your replies mean little.

Posted by: visionbrkr | August 28, 2009 2:42 PM | Report abuse

zzzzzzzzzzzzzzzzzzzzz. see i know how to shut him up.

Posted by: visionbrkr | August 28, 2009 2:49 PM | Report abuse

The bill in congress does NOTHING to make ANYTHING more 'affordable.' It only makes it so people who don't get the services have to pay for them (otherwise known as taxes, or having someone take your money from you by threat of gun or prison).
That does NOTHING to make it affordable.
The local children's cancer center has raised about 1/2 a million dollars this week for their center. It's amazing, in today's climate, to do that. Something like that, after we have 'govt' health care, will not happen. I couldn't see it happening. The government will be telling us: don't worry, we'll take care of it. And well, they might for a while. But there are reasons that medicare and social security are going bankrupt and are bankrupting the country. We have cowards who are supposedly our leaders. Look forward to more of that when they take over, and it doesn't look like they won't. Good luck with that.

Of course there's rationing of care. There always will be. And it's not 'rationing' because your insurance company doesn't cover it. You can go pay for something yourself if you'd like. Go ahead. No one's stopping you.

We are in for a whole lot of what's the worst in canada or the UK - and it will be a whole lot worse than that. They have US here to subsidize them, to be here to innovate for them. And, well, it goes without saying that they also have more money to spend on health care (and everything else) because WE have a military that the world looks to - and yet, well, they don't.
Everything's rationed, yes. But I don't want the government rationing it - I much prefer the market system (and before you say: it isn't working - um, get the govt out of the way and it would work a whole lot better).

Posted by: atlmom1234 | August 28, 2009 2:52 PM | Report abuse

@ronjaboy

Hey you got it. We ration everything by price. There aren't unlimited healthcare resources, so we allow the price to rise to a point where only some people can access it based on how much money they have. Is this the most socially useful way to ration healthcare? NO! A rich 80 year old guy gets a marginally effective bypass surgery that extends his life 1 year, while a 40 year old poor person who has 40 years of productive time ahead of him dies because he can't afford heart bypass surgery because he can't afford insurance. It is "the American way."

Posted by: srw3 | August 28, 2009 2:55 PM | Report abuse

SRW- If you believe that we ration gasoline in the US then I don't think you have ever been around real rationing.

Posted by: spotatl | August 28, 2009 2:59 PM | Report abuse

Seriously by your definition we ration food in the US. Pretty amazing we have such an obesidy problem when we are already rationing food.

Posted by: spotatl | August 28, 2009 3:01 PM | Report abuse

@spotatl

Well, what term would you like to use? Rationing gas by saying you can only buy 10 gallons at a time rations by proximity and price. If the station only has 1000 gallons of gas, and the price is set then the first 100 people (with the MONEY to pay) get the gas because they were there first. If there is only 10 gallons of gas left in a can and the owner holds an auction for it, the person willing to pay the most gets that 10 gallons. That is rationing by price only. Make sense?

Posted by: srw3 | August 28, 2009 3:04 PM | Report abuse


This should really be reported as:
27 percent of Canadians waited more than four months for surgery, 6 percent waited forever.
5 percent of Americans waited more than four months, 24 percent waited forever.
Which would you prefer?

*******

not a very smart question to ask. do you really want to know the answer? since i have insurance, and thus can afford things, i dont want to change a thing, and really couldnt care less whether the bottom 15% are denied care some of the time or have to wait for it all the time. its really not my concern. and since my most americans are in my position, chances are they dont care much either. there are a lot of things in the world that you could construe as moral outrageous, lack of universal health care insurance coverage is just among a pile of arguable cosmic injustices--and nothing more.

Posted by: dummypants | August 28, 2009 3:09 PM | Report abuse

@spotatl

We must ration food by price because in the midst of plenty, with enough food to feed every american, many people go hungry in the US. We do provide food (surplus cheese, food stamps, etc.) to some of the needy, but food insecurity is a real issue for the poor in the US. Even though there is plenty of food available, it doesn't get to those who need it but can't afford it. You could say the same thing about housing. There are lots of homes/apts for sale/rent, but most homeless people can't afford them, so we ration housing by price. Public housing does provide some relief and is rationed by time...When there are more applicants than subsidized units, the people (who meet certain requirements) first in line get the units and the others have to wait until one opens up. So yes, it is the american way to ration most everything by price, instead of say need, merit, return on investment, etc.

Posted by: srw3 | August 28, 2009 3:14 PM | Report abuse

srw3,

so when you change your individual coverage from a $20 copay to $50 you're rationing right? It doesn't mean you don't get the care you need if you don't pay for it. There are no limited services for the most part as of yet. When we don't have enough doctors to care for 150 million extra office visits per year (3 per person is the average) then you'll get to see real rationing. And then it'll be applicable to all regardless of wealth.

Posted by: visionbrkr | August 28, 2009 3:15 PM | Report abuse

If you believe that we ration food in the US then I think you are flat using the term incorrectly. I don't know how else to explain it to you. Its clouding your whole judgment of the healthcare issue evidently and I think we will always talk past each other. In Cuba they ration food- in the US we do not ration food. I have no idea why this is tough for you to understand.

Posted by: spotatl | August 28, 2009 3:20 PM | Report abuse

@atlmom1234

Straw man alert!!!!!!!

Most of your meaningless rant is not worth responding to, but I would point out that NO ONE is proposing a system anything like what Canada or Britain have. Canadians have medicare for all and no one in congress or the white house is proposing allowing or forcing everyone to join medicare, even though many people including me would like to. Britain's system is like the VA health care system and no one in congress or the white house is proposing creating a VA system for everyone in the US.

As for " get the govt out of the way and it would work a whole lot better"? Well, tell that to people who pay premiums for years and are then dropped because they actually need an expensive treatment or because they neglected to include an unrelated or incidental condition on their application years before. That unregulated free market, what a joy...

Posted by: srw3 | August 28, 2009 3:29 PM | Report abuse

@spotatl

Here is a rationing by need scenario. 10 lbs of food, 11 people,10 equally needy and one who has all the food s/she needs/wants. Each needy person gets 1 lb of food and the person with food gets none. This is a grossly simplified and idealized Cuba model (at least in theory), right?

Here is a rationing by price scenario. 10lbs of food. 10 equally hungry people, but only 2 people have money to buy the food. The two people with money get to buy the food and the other 8 people starve. Rationing by price.

Posted by: srw3 | August 28, 2009 3:42 PM | Report abuse

srw3,

actually Rep Weiner and about 50 other liberal democrats are actually proposing HR 676, Medicare for all.


And you all can keep up your "insurers are going to drop you scare tactics" but you do realize that EVERY BIT of legislation out there gets rid of that. Also all insurers are on board with that and IN FAVOR of that as long as all people are covered or as close to all people (ie individual mandate).

So which is it, are costs rising so great because insurers pay too many claims or are they denying every large claim that comes in???

Wait, maybe they're in "cahoots" with the hospitals and are sharing their padded charges? If you heard anything of hospital insurer negotiations you would know they get very heated and over the last several years are spilling out into the press.

Posted by: visionbrkr | August 28, 2009 3:52 PM | Report abuse

Can we all agree that someone sporting a picture of Obama with a Hitler-mustache is, ipso facto, a complete jerk?

Posted by: leoklein | August 28, 2009 4:09 PM | Report abuse

One should note that Krauthammer was merely cherry-picking statistics because he, himself has a be in his bonnet about health care reform. He chose, specifically, Canada and England to compare to, not, say, France or Germany. He did this because he knew it would make readers upset. Or he's not that bright, which is also possible. Odds are he was working off of a cribbed set of talking points handed to him when he said, "I want to write an op-ed opposing health care reform."

It may surprise many people, but there are other modern countries with universal health coverage other than Canada and England.

Posted by: constans | August 28, 2009 4:14 PM | Report abuse

@visionbrkr
I stand corrected. I should have said, the bills passed out of committee by the house and senate don't include medicare for all.

My post on recission and dropping folks who get expensive to treat illnesses was reflecting the current state of health care. It's not scare tactics. It's what is happening now. And there is no guarantee that it will change with the repiglicans opposing almost all health care reform, especially in the senate.

Costs are rising because the 6 companies that control 75% of all health insurance have effective monopoly control of the market and can set premium prices.

Posted by: srw3 | August 28, 2009 4:26 PM | Report abuse

I think it's important to emphasize that they (Euro's) wait for ELECTIVE SURGERY, not vital services. Many people hear about waits and pictures sitting in line with a heart attack. That's no so.

It's their way to manage a line, and keep things efficient. Basically, schedule that surgery that you want, but don't need, then bump it back if the hospital is very busy serving vital concerns.

I don't want waits either, but my father in law is hooked on 'elective' surgeries. I can see the logic in putting those things in a second category of importance. He thinks another shoulder surgery will make him golf like a 30 year old, while his actual body is 70. He gets priority in our current system. It's insane.

Posted by: rat-raceparent | August 28, 2009 4:49 PM | Report abuse

Let me observe that according to the encyclopedia Brittanica rationing is:

"Government allocation of scarce resources and consumer goods, usually adopted during wars, famines, or other national emergencies."

All the other definitions I found are basically the same.

So claiming insurance companies restricting what they will cover rationing is incorrect. What is happening is that insurance comapnies restrict access based on how much it will cost.

Posted by: werehawk | August 28, 2009 4:49 PM | Report abuse

By the way, if you want breast implants next week -- no problem!!!

That gets to status treatment here, since the $$$'s good, we have more than enough doctors serving the soon-to-be horizontally enhanced folks. If you're poor and need an infection cured, good luck.

Dummypants,
I'd take exception to your argument. I have great health insurance and care. But, not everyone lacks morality.

Posted by: rat-raceparent | August 28, 2009 4:54 PM | Report abuse

The people arguing that EK is using the term "rationing" incorrectly are (probably disingenuously, in my opinion) missing the entire point: this is the only definition under which "OMG GUMMINT GONNA RATION" is a valid claim. Until the government legislates procedures out of existence -- or, hell, until it prohibits private insurance -- its decisions about which procedures to pay for can be called "rationing" only under the loosest possible definition, at which point innumerable other features of modern society can be equally considered "rationed."

Posted by: bjrubble | August 28, 2009 5:26 PM | Report abuse

atlmom1234 --

“The bill in congress does NOTHING to make ANYTHING more 'affordable’”

Sorry. Wrong.

The reform program in congress has the IMAC program as part of it. It would give the IMAC board the right to make changes in Medicare and in any other federal program to cut back on unnecessary, ineffective management and to encourage management proven to be more effective and cost-effective.

Private insurers have indicated – as in they said they would do it – that IMAC decisions would give them the traction to implement many of those decisions in their own program without worrying about loss of customers.

As the tea-party stalwarts are saying, “Read the bill.”

In fact, the IMAC idea is the source of the complaints that the tea-partiers are addressing when they claim there will be “rationing.” It is of course not rationing, unless you believe that insisting on effective care is rationing.

As long as I am at it, in re the idea that rationing can occur only in government programs, that is plain nonsense. During the height of the gas price crisis, Toyota described their distribution pattern to their dealers for the Prius as “rationing.” Toys ‘R’ Us described their restriction of the number of Cabbage Patch Kids dolls a single customer could buy as “rationing.” Gasoline companies have rationed gas purchases during times of shortage, including the post Katrina period SpotAtl mentions and during the OPEC crisis in the Nixon years. I could go on. Businesses frequently describe distribution of items where demand exceeds supply as “rationing” when they make efforts to fairly distribute the product among their customers to avoid alienating customers, discourage hoarding, and prevent profiteering.

Posted by: PatS2 | August 28, 2009 5:33 PM | Report abuse

"Rationing" by price is a complete misuse of the concept of rationing, which always involves the intent on the part of the one providing the good to deprive. A person who sells something at a given price which some can afford, and others cannot, has no particular intention. He has just priced the food, and is neutral about who gets it. The entity doing the rationing says, "you cannot have this" no matter what. When gas was so high last year, you never heard people speak of its being rationed. That's because people really understand the difference between rationing and not being able to get what they want. No one goes around saying now that their healthcare is being rationed. That idea is strictly used by those promoting Obama's (or whoever's -- anyone actually know the authorship?) plan.

Posted by: truck1 | August 28, 2009 5:37 PM | Report abuse


It's specious to compare health care insurance to buying cars. There are certain basic rights a civilized society recognizes and access to medical care should be one.
Posted by: phsato | August 28, 2009 2:41 PM

---------------------------------------------

(1) There's a fundamental difference between buying a car and buying healthcare. A car you have time to figure out what you want and shop around.

I'm not aware of any instance where someone having a heart attack, or going into shock, shopped for the best deal on a hospital before they went to the ER. To truly shop around you need time, information, and above all a level-playing field. If you think somethings wrong you don't necessarily have a lot of time to shop around, and your paying the doctor to find out what's wrong with you.

Insurance policies. Okay, so maybe you have the time and maybe you even have information. Depending on your health status you may get charged more, or even be uninsurable. I wouldn't call the current state of insurance a level-playing, far from it. Leveling the playinf field means insurance companies have to compete for everyone, even the sick.

(2) Rationing.

Rationing is going to occur whether you want it to or not--healthcare is a finite resource, and there is a near infinite demand for it. The real question shouldn't be: will there be rationing--there already is (every healthcare system will have rationing) but what is the best way to ration care?


Posted by: UnPatriotic | August 28, 2009 5:50 PM | Report abuse

The fact that a good is scarcer than the demand for it does not make for rationing. If that were so, diamond rings would be rationed. It takes an entity at the other end with the intent to allocate, for rationing to occur. Scarcity, dearth, and famine may have results similar to or the same as rationing, but are not the same thing. Because in theory, if not in practice, an individual could overcome that scarcity by his own effort. With rationing, not. You are now falling back on the idea that the need for healthcare is more serious than the need for a car. Okay. But what about housing, food, and other basics? Those are being rationed, as well, because some people have mansions, and some are sleeping under bridges? Has rationing occurred? Housing is as serious a need for life as healthcare. Rationing is the imposition of deprivation by an individual or entity with the strength to block access to the deprived goods by anyone who wants it. Rationing is an active event -- to ration is a verb. People have referred to rationing by price. Who is price?

Posted by: truck1 | August 28, 2009 6:02 PM | Report abuse

the level of retardedness in the mind of a liberal trying to define rationing is hilarious. It has an actual definition, look it up. really. there's like a lot of info describing price and non-price rationing. they are not the same thing. Klein is a klown

Posted by: permagrin | August 28, 2009 6:20 PM | Report abuse

by some people's definition on here Medicare rations preventative care for seniors right now. They also ration care for macular degeneration too.

So is government rationing good and private rationing bad???

Posted by: visionbrkr | August 28, 2009 7:09 PM | Report abuse

By the way, if you want breast implants next week -- no problem!!!

That gets to status treatment here, since the $$$'s good, we have more than enough doctors serving the soon-to-be horizontally enhanced folks. If you're poor and need an infection cured, good luck.

Dummypants,
I'd take exception to your argument. I have great health insurance and care. But, not everyone lacks morality.

Posted by: rat-raceparent | August 28, 2009 4:54 PM | Report abuse


-------------------------------------------

absolutely. and my state of NJ has 45 mandates as of today's date. Some are good like autism coverage but some are just God-awful like infertility that studies show add 8% to the cost of EVERYONE's coverage in NJ.

i'm sorry if you can't have kids but I don't want to pay for you to keep trying and then in turn have multiple births. We've got one Octo-mom already and its one too many.

Personally I think Ezra should do a column on mandates. that would be enlightening for many on here.

Posted by: visionbrkr | August 28, 2009 7:14 PM | Report abuse

Jumping in here late, but according to some previous posters definitions or rationing (e.g., spotat and truck1), Britain and Canada do not ration health care either. If you have the money, you can purchase all of the private health care you want, in both countries.

Posted by: billatcrea | August 28, 2009 7:27 PM | Report abuse

Will you pedants please ST*U about the definition of "rationing"? The point is that health insurance companies, today, in the system we have now, are *already* making decisions about whether or not your life is worth saving. It's silly to pretend that our current health insurance plans guarantee treatment for all, when we know that our coverage can be terminated or specific treatments denied for seemingly arbitrary reasons, anytime and without warning. This is what health insurance reform is meant to address.

Posted by: tbomb | August 28, 2009 8:04 PM | Report abuse

Canadians typically come down here . I haven't heard of them purchasing more up there. This supposedly "broken" system attracts people from all over the world seeking the best care. Will that high level of practice and research continue under socialized medicine? Not known, and not thought about. The president says the system is "broken." "broken." uh huh. Also, under Hillary's plan, you definitely could not buy all the care you wanted. Doctors were themselves under restrictions about providing care to those outside their network. Who would get to go to the big research centers for cancer, for instance, was not spelled out. Probably families of administration officials. But who knows. In these systems, not only patients, but doctors are controlled. I don't think that in Canada they can offer patients something beyond what is allotted for everyone (government officials and families excepted).

Posted by: truck1 | August 28, 2009 8:08 PM | Report abuse

That's the point.

Posted by: billatcrea | August 28, 2009 8:09 PM | Report abuse

Why do people not understand that EVERYTHING is rationed? Great Zeus, people! Maybe the reason we pay so much for health care in the US is because the diagnostic equipment has to undergo expensive modifications in order to see through our thick skulls.....

Posted by: bradwright1 | August 28, 2009 8:10 PM | Report abuse

truck1,

I have clients in Canada that do purchase "supplemental coverage" up there. Insurers like Great West, Sun Life for example offer it. www.greatwestlife.ca is a site where you can view it to get a better perspective.


tbomb,
as far as rationing goes if time permits it i'm going to spend part of my weekend looking up the mandates in every state. (I know there's a matrix somewhere or there should be).

There are many states to my understanding where state law doesn't allow pre-ex or allows it for a short time or in very limited form. The problem is many of the legislators either don't know this (such as my love Rep. Pallone (which is really scary) or they choose to ignore this fact because it doesn't push their agendas whatever they may be.

Posted by: visionbrkr | August 28, 2009 8:18 PM | Report abuse

Some of the fear of change could be eliminated IF the political and business establishment would agree to go after the illegal population and drive them out of the country. But they won't. Nope.

So, if the whole world can come to the US, how will our health system operate?

Posted by: rusty3 | August 28, 2009 8:47 PM | Report abuse

oops. I meant "such as my loveLY Rep Frank Pallone" in a sarcastic tone.

Ezra if you EVER adjust a post please adjust the above one!

Posted by: visionbrkr | August 28, 2009 8:55 PM | Report abuse

Visionbrkr:

In Canada, people are allowed to buy supplemental insurance to cover services not covered by the provincial health insurance plans. For example, drugs, dental care, eyeglasses, medical supplies like wheelchairs, and so on. Low income people get supplemental coverage for free from the provinces.

In some provinces which have co-pays and premiums for the provincial health insurance plan (there are really 13 different health plans in Canada, one for each province and territory) the supplementary insurance can be used to cover those, like US Medicare supplementary insurance.

Canadians also can and do buy private insurance when they travel, especially to the US, since their insurance does not cover health care abroad under most circumstances.

Non-Canadians can also buy private insurance in Canada if their coverage from their home countries does not apply in Canada.

Generally, you cannot buy private health care outside the market in Canada, since providers are required to participate in Canadian Medicare in an "all or none" way. If they take none Medicare payment, they cannot get any further payment from Medicare. Canada and Sweden are alone in that restriction, since all other health plans allow supplemental private payment without penalty, including Britain.

However, another fluke of Canadian medical care is that workman's comp, which is seperate from the health plans, is allowed to queue-jump for service and pay extra for the privilege, and often does in some provinces.

Many private insurance programs in the US ration care as well, refusing payment for some services or treatments outright, requiring pre-approval for many services,and also having yearly and lifetime caps for benefits. As you have pointed out, that varies state by state, because of insurance laws.

BTW, Truck, I looked up rationing in five different dictionaries. The Britannica was the only one that specified that it implied government involvement. One definition, "capital rationing," is specific to business and has nothing to do with government.

Rationing refers to any effort to control distribution of a product in short supply by means of rules of distribution, regardless of who makes the rules. Diamonds, however, are not rationed except by price rationing, which is a seperate economic concept. They do have an interesting market control, because diamonds are actually withheld from the market by the cartels controlling diamond sales, in order to drive up the price from natural levels.

Goes to show you that cherry picking works for definitions as well.

And permagrin: you are right. The correct economic definitions do make a distinction between rationing and price rationing. However, if you can't afford health care, the pedantic definition is not very meaningful.

Posted by: PatS2 | August 28, 2009 10:38 PM | Report abuse

"see i know how to shut him up."

Some people have jobs where they get paid for the work they do, visionbrkr, while others just pretend to do them and get paid for showing up. Looks as if skimmers and pool-boys fall into the latter category.

Posted by: pseudonymousinnc | August 28, 2009 11:40 PM | Report abuse

"Not known, and not thought about."

Well, you're clearly not a thinker, truck1. A BSer, perhaps. But probably just a dumb repeater of dumb lies and dumb lines you heard on dumb radio shows and dumb Fox News.

For every foreigner who comes over to those elite clinics, there's a handful who end up in the urgent care clinics and E.R.s while over on vacation, and end up thankful that the travel insurance will cover the eye-splitting bills, and grateful for the systems they have at home.

It's not as truck1 has Mayo's in-network, and the poor dumb parrot's never going to be able to afford their fees out of pocket. But his masters will, and they'll laugh behind their back at him and the other rubes as they make do with doctors who might be fleecing them and insurers who'll screw them over.

Posted by: pseudonymousinnc | August 28, 2009 11:56 PM | Report abuse

PatS2,

thank you for what sounds like a solid background of the Canadian system. I have a client who is a multinational corporation who about 4 years ago opened up branches around Canada. I've stated this example on here before but maybe you can concur with it. Its an Indian based company. The employee and his wife had a high risk pregnancy in the US that was fully covered on their plan, just a $25 maternity copay. She was on bedrest for 2 months and the last month was spent in a hospital in VA because of complications. Several years later (about 2 years ago now) his wife was pregnant again and because of the nature of their employment they're transferred back and forth across the globe and they were transferred from Virginia to their Toronto office. We had to let him know that he had to wait 3 months to get his OHIP coverage and in the meantime he had to have a basic Welcome Plan which was not much more than glorified travel insurance and she wouldn't be seen by anyone until the 22nd week of the pregnancy while in the US he would have had substantial care up until that point. He was frantic. He begged and pleaded with his employer (even asked us to intervene for him with them) and thankfully they agreed and transferred him back to the US. that's the kind of care I'd be worried about if we ever went to single payer here in the US. Its not meant to scare anyone but to tell the truth about a real life story.

now if he was uninsured in the US she wouldn't have gotten any care so that issue needs to be fixed here as I've said plenty of times.

Posted by: visionbrkr | August 29, 2009 12:14 AM | Report abuse

pseudo,

again, no straight answer. anytime you want to be honest with us all go ahead. until then i can't trust a word you say until I know what drives your agenda. You know what I'm about but why are you hiding what you do???

Posted by: visionbrkr | August 29, 2009 12:16 AM | Report abuse

oh and i'm able to multi-task. if you're not then how is that my fault?

Posted by: visionbrkr | August 29, 2009 12:20 AM | Report abuse

When private health insurance companies look at their next quarter profit, they sum up potential incomes and then subtract from it their projected profit. What's left is to be rationed for our reimbursement losses.

At home, you also ration your spending. You will add up your expected income and subtract from it hopefully some saving. What's left is your disposable income for spending such as mortgage payment, out-of-pocket health care charges, food, cars, entertainment, or worse college tuition and parents' nursing home fees. You always need to ration your available resource, which is not unlimited. We have always rationed our health care, and we will continue to ration it. That's why we need the Public Plan to stretch every dollar we have for the best health care outcome.

Posted by: dummy4peace | August 29, 2009 2:41 PM | Report abuse

I would not argue that Canadian Medicare in general or OHIP in particular is an ideal program. Canadians wouldn’t either. They would just argue that it is way better than the US system. However, it is inarguable that the results of the Canadian health care system, measured in overall statistics in almost any test of health outcomes, are much better than the US, and costs are much lower. To be fair, that is also true of programs in other countries like France, Japan, Germany, and the Netherlands that depend on private insurance, albeit much more tightly regulated than in the US. The Swiss program also depends on private insurance, and private insurers there actually have seen increased profits compared with profits before the program began in 1995.

However, the example you give – lack of coverage for three months for a pre-existing condition of pregnancy following a change in insurance vendors -- is hardly one in which US insurance does very well. In many private policies the entire pregnancy would not have been covered. A three month wait for coverage would be typical of very good programs. This of course varies from state to state depending on regulations, and from policy to policy even within insurance companies. You are certainly aware of this, since guiding people and employers through that thicket is what insurance brokers do. Your advice in this case, to keep the policy that was in force when the pregnancy began, was good. I am also a little surprised that the company was not able to bridge that gap by continuing the private policy over the period before OHIP kicked in. In fact, Americans in Canada do get coverage from their US insurance while in Canada. An acquaintance of mine who is a doctor in a Canadian city near the border told me the only reason he needed a full time billing clerk was for dealing with US insurance. For the company, even paying cash for the relatively inexpensive costs of the first 22 weeks of pregnancy management with then having the family then enter OHIP would also have saved them quite a bit of money compared with paying for a US family coverage policy over the same period, unless the woman delivered her baby before the 22 weeks were up.

Posted by: PatS2 | August 29, 2009 3:09 PM | Report abuse

visionbrkr --

I do not know the answer to this question, but I am surprised that Ontario would not have a special regulation for pregnant women, since adequate prenatal care is actually money saving for health systems and for insurers who end up with responsibility for coverage of potential complications for mother and child. Most national systems include special programs for pregnancy, eliminating co-pays, deductibles, drug charges, and so on for pregnant women. Most bend every effort to get women to enter the health system as soon as possible. A few years ago a doctor friend of mine was in London, and he was quite impressed with a widespread ad campaign that said “When you see this, see us. It’s free.” The accompanying picture showed a home pregnancy test with a positive blue line, and the ad ended with a national free phone line to contact the NHS. This is just good sense, because it saves a lot of money at very little cost. Preventing a single significantly premature birth would save enough to cover thousands of normal pregnancies.

This of course is a striking contrast to the US, where a significant number of pregnant women first enter the health system in labor, contributing significantly to our third world infant death rate.


Posted by: PatS2 | August 29, 2009 3:12 PM | Report abuse

Reason: Ezra Klein's Confusion Over "Rationing"
http://www.reason.com/blog/show/135766.html

Posted by: StewartIII | August 29, 2009 11:15 PM | Report abuse

StewartIII –

The Britannica definition, apparently now very popular with conservatives, is not definitive by any means. Merriam-Webster, generally the definitive US dictionary, defines rationing without any reference to government. I surveyed six dictionaries. The Britannica was the only one to specify government involvement as a necessary component.

That said, there are separate economic definitions for rationing and price rationing. Both occur in US health care. Price rationing is our basic policy. Standard rationing occurs when insurance, both private and public, refuses treatments to insured. As I said earlier, the argument over syntax is pretty meaningless if you are the one being refused health care you believe, correctly or not, that you need.

The article in “Reason” is interesting because it is proposing a solution not much different from successful programs in Germany, Switzerland, and the Netherlands. The one thing is that the regulations they mention need to be very strict, or else the cost of health care will shoot through the roof. Control of premium costs for basic required insurance, specification of features including out of pocket costs and guarantees of coverage, and control of utilization through regulation by some IMAC like agency to require that care be effective, cost effective, and not harmful is imperative as well.

These types of programs, generally called “social insurance” systems, work very well where they are used if and only if they have these features.

Posted by: PatS2 | August 30, 2009 11:06 AM | Report abuse

I find myself longing for the days when state-of-the-art medical care wasn't a luxury item and was available to all. If only it could be that way again!

I mean, such times did exist, didn't they? We're not trying to do something silly like Yacht Reform, are we?

Posted by: ktcat | August 30, 2009 11:34 AM | Report abuse

The definition is getting confused because it's usually government that does the rationing. But government is not essential to the definition of rationing. To ration is to apportion, to say to individuals, thus much and no more -- about how much of a good they can have. It takes power to deprive people of something they want more of -- which is why states are almost always the rationers. There must be an acting being or entity that does the rationing. You can't say that on a cloudy day sunlight was rationed, or that gas, when it becomes terribly expensive, is being rationed. No one said that last year, though the outcome for many was the same as if it had been rationed. Sameness of outcome is not the issue, but Klein and others try to reason backward from the outcome. Saying "we ration" four, five, ten times will not make it true, and people instinctively know that it's a lie.

Posted by: truck1 | August 30, 2009 12:22 PM | Report abuse

We ration! We give up our freedoms! We act like sheep! We watch Ezra slobber all over himself when he talks about Obama!

Posted by: johnhiggins1990 | August 30, 2009 12:50 PM | Report abuse

PatS2,

thanks for all your input. You truly know the systems of Canada it seems. Do you mind if I ask where your background from there comes?

Yes the employer (through myself) asked if we could adjust the system of insurance they had and were told they couldn't. Also the fact that they were not US citizens (but here on a work visa (I believe an H1 work visa) i believe factored into it. We also looked into keeping them on the insurance in the US and cover costs there but that wasn't feasible either. In the end the project was supposed to last 6 months for him and they found a suitable replacement that worked out for all.


And my view is tilted because I'm from NJ. A guaranteed issue state where I honestly don't see recission happening at all. I've been in this business for 15+ years (pretty much since our reforms happened in 1994) and I've seen a couple instances where pre-ex was applied and we're currently fighting with HOrizon BCBS on behalf of a friend who was denied claims because she legitmately had a period of time that pre-ex was applicable but we're trying to argue that her condition isn't related to the pre-ex. Its pretty complicated and we're not getting much help from the State of NJ.

Posted by: visionbrkr | August 30, 2009 1:23 PM | Report abuse

visionbrkr --

I am a doctor, and have practiced most of my 30 year career within spitting distance of the Canadian border. As such I run into a lot of Canadians in my town -- although I have to say that Canadians seeking health care in the US are rare, in my experience. Through meetings and education programs I have encountered many Canadian doctors. In general, I see a lot more Americans who are familiar with and know about the Canadian system and wish they were covered by it than Canadians who wish the reverse. Canadians are much more interested in shopping in the US -- our mall parking lots are full of Canadian cars -- than getting medical care here.

If you are interested in learning more about Canadian health care and health care in many other countries, there is a new book out by T.R. Reid called "The Healing of America." He reviews the health systems of Canada, Britain, Japan, Germany, Taiwan, the US, France, and Switzerland in detail, and talks some about other countries. He also reviews the major issues in health care. I think the book is quite fair, pointing out strengths and weaknesses of all programs (for example he talks quite a bit about waiting times for elective procedures in Canada and Britain.) He is not perfect: his estimate of incomes for US primary care is way high, and his estimate of malpractice costs in the US very high for all but a couple (OB and neurosurgery) specialties, and particularly for primary care docs who don't do deliveries. He also underemphasizes the role of overutilization of high tech management and its role in the very high cost of health care in the US.

However, it is by far the best review of foreign health systems I have ever seen, and a pretty good review of major issues in health care systems, including our own. It is short (250 pages), well written, not highly technical, and an easy, quick, pleasant read. Anyone like you who is interested in health care issues would find it very interesting and informative.

Here's an Amazon link for the book. It costs $14.27 in hard back or $11.68 on Kindle, but buy the hard back so you can loan it to friends.

http://www.amazon.com/Healing-America-Global-Better-Cheaper/dp/1594202346/ref=sr_1_1?ie=UTF8&s=books&qid=1251655760&sr=1-1

Posted by: PatS2 | August 30, 2009 2:20 PM | Report abuse

PatS2,

i appreciate your perspective as a doctor. I plan on looking up that book and getting it to get a better idea on the other systems in a non partisan way. I have a question for you. One of the things that frustrates me and I would think frustrates you as a doctor is step therapy for drugs. First off i'm no doctor and i wouldn't even try to be but every time we change an insurer we need to let them know that we've tried a statin that didn't work, we tried Zocor that didn't work and we need Lipitor that has worked. I think if we could find a way to get this info out there (on a proposed medical card) and have standard protocols for all insurers then we could save doctors offices time and money in man hours wasted. THere are of course some privacy issues with that but i've been spending the better part of a week now trying to help a client with that and I'm working with a doctor's office that has been very helpful but i also feel like I'm treading on ground that I don't honestly belong in in the interests of trying to get it resolved for my client. I'd be interested in your take on that. This is a failing to me in not only the private system that I'll readily admit.

Posted by: visionbrkr | August 30, 2009 3:38 PM | Report abuse

oh and while I'd like standard protocols for step therapy (from my understanding the guidelines that insurers take them from are from the AMA or other medical advisory groups) i also realize that we can't necessarily do that as it wouldn't be fair to a manufacturer if step one was a generic, step two was Brand A and step 3 was brand B. It wouldn't be fair to brand B.

I also think the thought that bureaucrats make medical decisions at insurers (like some believe) is absolutely wrong. Medical directors are always Medical doctors and most have extensive experience in their fields.

I'm also curious as to why the cost of MRI's haven't come down with how common they're done. X-rays used to cost a lot and have come down substantially from original cost but MRI's still seem to be very expensive and they don't follow traditional economic models of supply and demand in that way.

Posted by: visionbrkr | August 30, 2009 4:20 PM | Report abuse

"Healthcare is a commodity like anything else, some people can afford all they want or need and some people can't."

equals this:

"'Are there no prisons?"
'Plenty of prisons,' said the gentleman, laying down the pen again.
'And the Union workhouses.' demanded Scrooge. 'Are they still in operation?'…
'Many can't go there; and many would rather die.'
'If they would rather die,' said Scrooge, 'they had better do it, and decrease the surplus population."

People *die* when they can't afford health care. 18,000 a year, according to a 2004 study by the Kaiser Foundation (you know, the same people who provide really good medical care.) Those 18,000 deaths take a toll on many aspects of American life and are ENTIRELY PREVENTABLE.

Health care reform could save 18,000 American lives a year. I am more than a little appalled by those who oppose it.

Posted by: gregM2 | August 30, 2009 6:38 PM | Report abuse

Correction--the study's by the Institute of Medicine. It was quoted in a report by the Kaiser Foundation shortly after its release.

Posted by: gregM2 | August 30, 2009 6:39 PM | Report abuse

I think the easiest way to explain America's rationing of health care is as follows:

If you have a whole lot of money, you get a whole lot of health care.

If you have a medium amount of money, you get a medium amount of health care.

If you have a little bit of money, you get a little bit of health care.

Posted by: mzrk9 | August 30, 2009 7:08 PM | Report abuse

Visionbrkr –

The issue is not bureaucrats making decisions, it is following scientific evidence rather than advertising. The proposed IMAC board would be staffed by physicians and scientists and would have access to other researchers in doing their work. The question is whether you would like to have your medical care based on advertising and lobbying, or prefer science.

As far as step therapy to choose appropriate drug courses,
first, I believe that it is correct to start out with therapies that are safe, effective, and inexpensive, and switch to more expensive therapy only if the less expensive therapy fails. I do not think it is unfair to manufacturers of drugs to require that physicians and patients consult evidence on effectiveness and choose management courses based on a combination of proven effectiveness, cost effectiveness, and safety. Manufacturers should be rewarded for low cost and high safety and effectiveness, just as manufacturers of TV sets are.

In terms of drug therapy, the poster child here is antihypertensive therapy, where the ALLHAT study conclusively showed that the three least expensive therapeutic agents were also the most effective and the safest. Subsequent surveys showed a very high rate of physicians choosing more expensive, less effective, and more dangerous drugs, presumably under the influence of advertisements and drug detail people. It is certainly appropriate, in my belief, for insurers, both public and private, to insist that doctors follow the preferred approach, partly on the basis of effectiveness and partly on the basis of cost. One way or another, all Americans are paying money for the less appropriate approaches, and we should insist that it stop.

Posted by: PatS2 | August 30, 2009 8:14 PM | Report abuse

Visionbrkr --

In regard to your own issue regarding Lipitor. There is a generic version of Lipitor, equally effective. It will not be available until late 2011 as a result of settlement of a lawsuit between Pfizer and Ranbaxy over Ranbaxy’s intent to sell a generic version of Lipitor. The suit hinged on technical chemical issues. The generic Lipitor is already available in many other countries as a result of the settlement, and Lipitor itself is available at very low prices in many other countries.

There is an on-the-shelf solution to the problem of having to re-start the stepwise evaluation of drug prescriptions every time you change providers or insurers. A national electronic medical record would end that, since previous records would be immediately available. The most sophisticated example is the French and German medical record cards, which are in the patient’s possession, not the doctor’s or hospital’s but are presented at point of service to be read by card readers. Each card contains a chip carrying the patient’s entire medical history. For now, the best solution in most systems in the US is for the patient to get his or her paper medical record from the former provider and carry it to the new provider. However, in many systems there is a substantial charge for providing copies of the record, and in some there is a charge for looking at the record and incorporating it in the new record.

On to your question of MRI charges. The charges for the technical component of MRI – the cost paid to the owners of the machine and employers of the techs who run it – have, as you say, not decreased. The reason is the “new, improved Tide" argument. MRI manufacturers have successfully gotten users to do one of two things: buy expensive (as in hundreds of thousands of dollars every year or two) updates for existing machines or tear out existing machines and replace them with new ones at a cost of $1.5 million a pop. As a result, the technical charge has stayed high, often, depending on payer, even for machines that have not gotten the upgrades.

Meanwhile, the professional charge (doctor’s fee) for the radiologist for MRI has decreased strikingly, often by 50% or more. This has been led by Medicare, cutting their fees, and largely copied by private insurers, based on the grounds that MRI is no longer a revolutionary new technology but a routine part of practice. Medicare has also adamantly insisted on not paying for MRI studies that are not proven to be effective, with some but not all private insurers following along.

Don’t feel too sorry for the poor radiologist (disclosure: I am one.) The rapidly increasing numbers of MRI scans ordered by clinical physicians has more than made up for the income lost. There are no radiologists standing by the road with signs saying “will read MRI for food.”

Posted by: PatS2 | August 30, 2009 8:30 PM | Report abuse

I'm not sure your numbers are comparable. They may have different denominators. In Canada and Britain the % waiting more than 4 months may be a much smaller % of the population if it is based on the number of people who need to get procedures. In the U,S. the denominator may be a much larger number, if it is based on everyone with insurance or worse, everyone with or without insurance.

Posted by: awmarch1 | August 30, 2009 11:44 PM | Report abuse

PatS2,

Thank you. I sometimes have to remind myself that in my day to day dealings with doctors offices that are on behalf of my clients who are patients that are being treated by doctors that are either being mistreated by their insurer, got caught up in the system or in the rare instance where the doctor is looking to make a profit from something (ie owning a surgi center that doesn't partcipate in any network to make more money than having the doc pay admitting privliges at a hospital). I need to remember they are not only very rare but in the countless cases that I don't hear about the patient is being well taken care of, the system is working for them).

To that end I wish there were more doctors it sounds like you are and that could make the customer service aspect of my job obselete which i would welcome.

Posted by: visionbrkr | August 31, 2009 9:57 AM | Report abuse

I am pretty sure that the data on waits in the British and Canadian systems are properly calculated statistics, based on the total percentages of patients having waits. There are waits in Canada and Britain that are considerably longer than in most countries.

However, there are two big things about waits that need to be noted.

First, waits in Britain and Canada are only for exams and procedures where the patients’ doctors believe that the wait will not be harmful. Most are related to “gray zone” management, for treatment where there is no clear cut point in which the treatment has to or should be done. The decisions as to when to operate on cataracts, when to do hip replacement, when headaches should be evaluated by MRI, and so on are not clear cut. The question of when there is a clear indication for procedures is hard to answer. There is not a day when a patient wakes up and clearly needs cataract surgery – it is a progressive change, and the decision as to when to act is much more complicated than lots of people think. In my own family, both of my parents had cataract surgery in their eighties. My father decided to get his when his doctor told him that he would not pass his driver’s license eye exam; although he does not drive much, he does not want to lose that license. He had surgery and is satisfied with the results. My mother, on the other hand, was having gradually worsening symptoms but was not sure she wanted the procedure. Her doctor strongly suggested she would be happier, so she did it. In fact, she remains, three years later, unhappy with the results of the surgery, and believes her eyesight is worse than it was before surgery, mainly disappointed with the loss of accommodation that lens replacement causes, and that the procedure did not give her a twenty year old’s eyesight.

In fact, for every patient in Canada and Britain who waits for surgery, there is an American patient who had surgery before it might have been best, with associated exposure to risk of surgery and to risk of bad results. The procedures are not magic. Like all medical procedures there are risks and there are poor results.

Second, waits do not characterize most government health programs around the world. In the US, almost all cataract surgeries and most hip surgeries are done on Medicare patients, and an additional number are done on Medicaid and VA patients. There are no complaints of waits being too long. Germany, France, Japan, Taiwan, and many other countries have waits that are no longer and sometimes shorter than our own. The primary cause of waiting in the US in both private and government health care programs is patient indecision about the procedures and matching procedures to the surgeon’s schedule.

There is no reason to suppose that having more patients covered by Medicare- like programs would lead to waits, any more than Medicare leads to waits now.

Posted by: PatS2 | August 31, 2009 11:05 AM | Report abuse

lets not forget that both canada and britain spend about half as much as we do for about the same results. If canada or britain doubled the amount of money they spend waiting would probably be eliminated for routine, non emergency procedures as well.

Posted by: srw3 | August 31, 2009 4:47 PM | Report abuse

Britain has actually shortened wait times significantly for most procedures since the 90's, when the Blair government made it a priority. They still have some waits, but waits have decreased from a year or more to 2 to 3 months.

Canada was working out deals to decrease wait times when they got sandbagged by the recession. It remains a priority, but is on hold for now.

Posted by: PatS2 | August 31, 2009 5:21 PM | Report abuse

Mr. Klein's line of reasoning fails to distinguish between earning one’s keep and getting something for nothing, between government force and voluntary trade. As any honest man knows, one cannot consume what one has not produced. As any honest man knows, one can morally consume what another has produced only after acquiring it by voluntary means…by trade or private charity. As any honest man ultimately knows, one cannot consume in excess of what one earns.

Being unable to afford the price of what someone else produces is not rationing, despite the fact that that term is sometimes used in reference to the laws of economics. Your money represents the value that you have created for someone else through your productive work ... be it a product, service, your labor, or what have you ... in a voluntary trade. You then use your money to purchase the healthcare you need in the same manner … by voluntary trade, on mutually agreed terms, to mutual benefit. If no voluntary agreement is reached, no trade takes place. The fact that one person can’t pay for a medical procedure, while another can (whether in cash or some other means such as a prior contractual agreement like insurance), is not rationing. Nor is it unfair in any way. In a health care free market - which America’s semi-socialist, semi-fascist, government-controlled system is not - physical force is absent.

Government is a unique institution, possessing a legal monopoly on the use of physical force. When government runs healthcare, it must necessarily use its coercive powers to dictate who gets what healthcare when, because when government pays, government sets the terms. The winners are the moochers, the losers are the self-supporting. The essence of government rationing is to forcibly deny health care to those who have earned it, for the sake of those who haven't. The essence of market "rationing" is justice ... each person must earn his health care, by his own effort, in voluntary trade with providers. To advocate the former over the latter is a moral perversion. But then, socialism in all of its collectivist forms is a moral perversion.

Rationing is government distribution of goods and services, as in both World Wars. It is force, and nothing else. There is no coercive central distributive authority outside of government (or government controlled quasi-private insurance giants), only millions of individuals producing and trading by mutual consent. But however one chooses to define rationing, the choice is stark. The choice is voluntary human association or brute bureaucratic state force; earned wealth or the unearned; market justice or "social justice"; the risk of going without or government dependence; the dollar or the gun; freedom or slavery.

http://www.principledperspectives.blogspot.com/

Posted by: Zemack | August 31, 2009 8:45 PM | Report abuse

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