Does The U.S. Ration Health Care?

It is a widespread myth, long a meme, among conservatives and many in the public that national health insurance would be "government-run" health care with rationing of services, as opposed to the free market offering more choice without rationing.

Here are examples of this deceptive, misguided, and uninformed mantra:
  • In the debate over the Affordable Care Act in 2009, Sarah Palin, former governor of Alaska and candidate for vice president, had this to say about the ACA's coverage of physician visits for seniors to discuss living wills and other end-of-life issues:
  • Who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down's Syndrome will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care. Such a system is downright evil. (1)
  • This concern by Sally Pipes, president and CEO of Pacific Research Institute, a right-wing think tank:
  • Once the government takes over the healthcare system, it's nearly impossible to undo the damage. That's why U. S. lawmakers must repeal and replace Obamacare sooner than later. Canada proves that single-payer health care inevitably results in rationing and lost lives. Government-run health care is one Canadian import we should turn away. (2)
These kinds of views presume that our free market-based system offers full choice of health care without rationing--completely untrue.

Rationing in our present multi-payer system
These are some of the many ways that we ration health care in our largely private, under-regulated for-profit health care marketplace:

  • By insurance status. Six years after the passage of the ACA, we still have almost 30 million uninsured. Among the uninsured, tens of thousands die each year because of lack of health insurance. (3) There are also tens of millions of underinsured without access to necessary care.
  • By high prices and unaffordable costs. The costs of health insurance and care have reached more than25,000 a year for a typical family of four insured by an average employer-sponsored PPO (4), having doubled over the last ten years--clearly a huge burden when we consider that the median household income is now about53,000.
  • By decreased choice and access. Even with the ACA, insurers have many ways to limit choice and access to care, including high-deductible plans (annual deductibles of5,000 for an individual and10,000 for families are part of bronze policies), narrow networks without coverage of out-of-network costs, high co-insurance for specialty drugs, restrictive definitions of medical necessity, and denial of services.
  • By employers' cutbacks. There has been a large cost shift from employers to employees in employer-sponsored health insurance as employees find themselves with higher deductibles, higher coinsurance, and a higher share of premiums. (5)
  • An underfunded, tattered "safety net." Political decisions in 20 states rationed care by not expanding Medicaid under the ACA, leading to a projection that more than 7,000 people will die without access to necessary care in those states. (6) Moreover, the ACA resulted in a Medicaid coverage gap affecting almost 5 million Americans who fell in between eligibility requirements of the ACA and the states, and consequently had no insurance. (7).

Rationing in countries with national health insurance
Countries with universal access provide comprehensive benefits with greater efficiency and value, at far less cost than in the U. S., and also with better outcomes. (8)

It is useful and necessary to "ration" services that are not efficacious or cost effective based on scientific evidence, as is done successfully by such countries as the United Kingdom, with their National Institute for Health and Care Excellence (NICE). We do the opposite with our industry-friendly FDA approval process. One good example of that is the FDA's approval of a 23 mg dose of the Alzheimer's drug Aricept despite the lack of clinical evidence that it is better than a 10 mg dose and without concern that patients taking the larger dose stopped taking it twice as often due to adverse side effects. (9)

All health care systems ration care one way or another. There are good ways and bad ways to do it. Ours is a bad and irrational way. It allows for excess, often inappropriate and ineffective care for those who can pay and exclusion of those who suffer worse outcomes due to lack of access and affordability. It is unfair and inhumane when so many millions of Americans cannot gain access to necessary care because of financial barriers. As a result, we have a system of rationing based on ability to pay without regard to medical need. Moreover, we still have no significant containment of prices and costs of health care as well as the worst health care outcomes compared to ten other advanced countries, including Canada. (8)

Without looking at the experience of countries around the world with one or another kind of universal coverage, opponents of single-payer national health insurance (NHI) claim that it will ration care to their detriment. But they deny or seem unaware that we already ration care way beyond what NHI would do. This denial is a moral blind spot for our society, as our country still does not recognize health care as a human right, as do most other industrialized countries around the world.

The rising burden of health care costs is unsustainable for patients, families, and taxpayers. We will have to deal with it sooner than later. When that time comes, we will have to take a societal perspective in deciding, based on scientific evidence, what services can be provided for all Americans, not just the most affluent among us.

1. Palin, S. as quoted by Drobnic, A. Sarah Palin falsely claims Barack Obama runs a 'death panel.' Politifact, Truth-o-meter, August 10, 2009.

2. Pipes, S Don't import Canada's ideas on health care. Real Clear Politics, April 28, 2015.

4. Milliman, 2015 Milliman Medical Index. May 2015.

5. Spiro, T, Calsyn, M, O'Toole, M. The great cost shift: Why middle-class workers do not feel the health care spending slowdown. Center for American Progress, March 3, 2015.

6. Dickman, SL, Himmelstein, DU, McCormick, D et al. Health and financial harms of 25 states' decision to opt out of Medicaid. Health Affairs Blog, January 30, 2014.

7. Appleby, J, Gorman, A. Obamacare enrollment: second year even tougher. Kaiser Health News, October 6, 2014.

8. Davis, K, Stremikis, K, Squires, D et al. Mirror, mirror on the wall, 2014 update: How the U. S. Health System Compares Internationally. The Commonwealth Fund, June 16, 2014.

9. Holzer, B. FDA ignores negative feedback on Alzheimer's drug Aricept. Public Citizen News 31 (4): 20, 2011.