Viewpoint
Rationing Reasoning
By Richard De Filippi
“Rationing” is any public policy allowing essential health care services to be systematically withheld from a broad population because of scarce resources. It is an extreme form of denying health care access, and one that most of us are reluctant to face, even though many, both inside and outside the health care field, say it is inevitable.
My goal here is to examine rationing, not because I think it is a viable solution to the problem of affordable health care, but because I feel that exposure of the painful issues raised by rationing could help drive much-needed change.
A clear-eyed discussion of rationing might help us face the fact that our health care system is broken. It may help us find the will to implement real reform. If that were to happen, rationing should cease to be an issue.
Rather than focus solely on the specter of rationing, I’m making a plea that we turn our fear of that specter into the resolve we need to fix our broken health care system.
Why are we having difficulty learning the lessons of other industries around us? So much has happened, for example, in the production of automobiles, and we all have graphic evidence of it.
The first car I ever owned was a hand-me-down Studebaker with a deeply troubled oil-consuming existence. It finally died a smoky death at less than 80,000 miles, all the while putting a huge dent in my grad-student budget. Fast-forwarding to the present: I own a 1988 Toyota 4x4 pickup with close to 200,000 miles, and it survives on fewer maintenance dollars than that Studebaker burned up many years ago.
Sometime in the intervening years, the automobile industry made investments in improving the way they made cars, absorbing new technology with the express purpose of increasing productivity by both reducing costs and improving quality. It took a long time, and the path was far from direct, but it happened. Even more interesting, it appears to be happening again right now in the face of new challenges.
This kind of improvement has not taken place in the nation’s health care industry. As a society and a national culture, we seem unable to find the imperative. Instead, like the automobile industry 50 years ago, we tinker with last year’s model, searching in the same old over-explored corners for solutions.
How can we begin to find the solutions we need? One way is by investing our health care dollars in ways that begin to redress the extreme imbalance between our current allocation of resources and the factors that have an impact on health.
For example, the U.S. Department of Health & Human Services report Healthy People 2010 attempts to estimate the degree to which various factors influence health: lifestyle constitutes about 50 percent; biology and the environment each have about a 20 percent impact on health. At the bottom of the list is medical care, accounting for only 10 percent.
We spend $2 trillion a year on medical care to attack a small fraction of the cause of ill health. We spend proportionally far less on public health, health education and related basic and applied research—areas that could help address 90 percent of the factors that have an impact on health.
We need our best minds and our best resolve to come up with the kind of changes we must make to reform our health care system. As with all new ventures, the increased investment will be costly at the beginning, but that initial investment will give us positive returns for the future that go far beyond saving money.
If we are able to consider an extreme solution to our health care problems—rationing—why couldn’t we first revisit our national values and priorities and then debate our willingness to sacrifice collectively in other ways to find the investment needed for health care reform?
Political absolutes on tax increases may look very different when a congressional debate on health care rationing appears on C-SPAN.
Indeed, even if that debate is still in our future, it would have an entirely different moral tone after it had been placed properly in the hierarchy of our social responsibilities.
Richard De Filippi is a trustee and former chair of the Cambridge (Mass.) Health Alliance. He is also the AHA Board of Trustees 2009 chair-elect. He can be reached at rdef@ariano.com.