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How Would You Like Your Rationing -- Rational, or Irrational?

Several years after making headlines for its health care reform, Massachusetts is back in the news, this time for passing legislation that aims to impose a cap on overall health care spending. That ambition implies, even if it doesn't quite manage to say, a very provocative word: rationing.
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Massachusetts has a long track record of making headlines in the area of health care reform, whether or not Mitt Romney likes to talk about it.

In 2008, Massachusetts released results of its initiative requiring virtually all of its citizens to acquire health insurance. In short order, nearly three-quarters of Massachusetts' 600,000 formerly uninsured acquired health insurance, most of them private insurance that did not run up the tab for taxpayers. The use of hospitals and emergency rooms for primary care fell dramatically, translating into an annual savings of nearly $70 million.

But that's pocket change in the scheme of things, so the other shoe had to drop -- and now it has. Massachusetts is back in the news, this time for passing legislation that aims to impose a cap on overall health care spending. That ambition implies, even if it doesn't quite manage to say, a very provocative word: rationing.

Health care rationing is something everyone loves to hate. Images of sweet, little old ladies being shoved out the doors of ERs that have met some quota readily populate our macabre fantasies.

But laying aside such melodrama, here is the stark reality: Health care is, always was, and always will be rationed. However much people hate the idea, it's a fact, not a choice. The only choice we have is to ration it rationally, or irrationally. At present, we ration it -- and everything it affects -- irrationally.

I can tell you from a doctor's perspective exactly why this matters. Some years ago, I was volunteering as a supervisor for medical students providing outreach in a homeless shelter in New Haven, Conn. I met a woman in her early 30s who was severely limited in her activities by shortness of breath, and listened to her story.

Months earlier, she had a brief illness and spent a few days in bed. When she got better and back on her feet, she noticed she had a pain in her left calf. She thought about seeing a doctor, but had no insurance and couldn't afford to go. So she just hoped the pain would go away.

It didn't; it got worse. But she didn't seek medical attention because of cost; it simply didn't hurt enough to justify spending money she needed for food.

Until suddenly, late one night, she found herself gasping for breath with stabbing chest pain. Naturally, she wound up in the emergency room via ambulance, and then the intensive care unit. She was diagnosed with a pulmonary embolism, a blood clot in the lungs. This condition can be fatal, and in her case, nearly was.

The source of a pulmonary embolism is usually a blood clot in the leg. In this case, that's just where it came from -- a blood clot causing pain in the left calf. When a clot in the leg is detected and treated early, a life-threatening pulmonary embolism is entirely preventable at fairly low cost.

This woman, a mother back then of a 3-year-old daughter, would never fully recover. Her health care costs ran to hundreds of thousands of dollars, a bill for the hospital, and by extension, the taxpayers -- namely us -- to pay. She had no means to pay it -- and didn't ask for the care in the first place. The shelter called the ambulance.

By denying this woman access to care she needed, or public insurance that would have paid the nominal costs of early care, our system resulted in both ruined health and a much bigger bill.

Unfortunately, I can tell this tale from a personal perspective as well. Some time back, a family member -- a healthy man of 32 -- noticed a discoloration on his skin, and saw a doctor. The doctor recommended that he go to a dermatologist. But just then, this man was leaving one job and looking for another. Naturally, that meant he was temporarily uninsured. So he decided to wait for his new job and his new insurance.

Some months later, with a new job, new insurance, and newly married, the man went to the dermatologist. He was diagnosed with malignant melanoma. It had grown since his first doctor visit, and try as they might, the surgeons could not get all of it. Following cycles of chemotherapy, the man died at age 34. Tragically irrational rationing.

In cases like this, people are paying with their lives for the gaps in our insurance system, something the health care reform of the Obama Administration at least partly addresses. There are costs to fix those gaps, yes -- but there are higher costs in not doing so. A skin biopsy is a minor expense. Extensive surgery and cycles of chemotherapy are enormously expensive, to say nothing of the economic toll of a working, productive young adult becoming a debilitated and dying patient.

In a system of universal, or nearly universal health insurance such as in Massachusetts, decisions about what benefits to include for whom are decisions about the equitable distribution of a limited resource. If that is rationing, then we need to overcome our fear of the word so we can do it rationally. By design or happenstance, every limited resource is rationed. Design is better.

In the U.S. health care system, some can afford to get any procedure at any hospital, others need to take what they can get. Some doctors provide concierge service, and charge a premium for it. Any "you can have it if you can afford it" system imposes rationing, with socioeconomic status the filter. It is the inevitable, default filter in a capitalist society where you tend to get what you pay for.

That works pretty well for most commodities, but not so well for health care. As noted, failure to spend money you don't have on early and preventive care may mean later expenditures that are both much larger, and no longer optional -- and someone else winds up paying. If you can't afford a car, you don't get one; if you can't afford care for a bullet wound -- if you can't afford CPR -- you get it anyway, and worries about who pays the bill come later.

But those costs, and worries, do come later -- and somewhere in the system, we pay for them.

By favoring acute care -- which can't be denied -- our current system of rationing dries up the resources that might otherwise be used for both clinical preventive services and true health promotion. Fully 80 percent of all chronic disease could be eliminated if our society really rallied around effective strategies for tobacco avoidance, healthful eating, and routine physical activity for all. But when health care spending on the diseases that have already happened is running up the national debt, where are those investments to come from? The answer is, they tend not to come at all. And that's rationing: not spending on one thing, because you have spent on another.

Nor is this limited to health care. The higher the national expenditure on health-related costs, the fewer dollars there are for other priorities, from defense, to education, to the maintenance of infrastructure. If cutting back on defense calls the patriotism of Congress into question, then classrooms get crowded and kids are left to crumble. Apparently, it is no threat to patriotism to threaten the educational status of America's future. Whatever...

The resources we ration may be laundered in such a way as to make the rationing invisible. Those little old ladies never actually do get shoved out the ER door -- or if ever that does happen, it's both illegal and a scandal that makes headlines. But our kids may well wind up in overcrowded classrooms with outdated textbooks, because the money ran out. That, too, is rationing.

Massachusetts has thus embraced nothing other than the inevitable in proposing that health care costs be capped. Colleagues and I went further in a program we called EMBRACE, published in the Annals of Internal Medicine in 2009. We actually suggested a rational approach... to rationing. For any hope of ever moving in that direction, we have to "embrace" the reality of limited resources and stop wincing every time we hear the word. All finite resources run out, and all resources are finite. We have to stop running away from this fundamental reality, and deal with it. No little old ladies waiting in the ER need be harmed in the process.

The more we spend on acute care, the less we spend on prevention. But also, the less we spend on other things that matter -- like books for our kids in school. The less we spend on books, and teachers, the lower the literacy rate. The less our literacy, the less our society is able to read the writing on the wall.

Right there, in bold lettering for those who can read it, is the time-honored message that rationing is inevitable. Whether rational, or irrational, however, remains a choice we can make. Here's hoping the experiment in Massachusetts may help show us how to make it wisely and well. Minimally, here's hoping it helps us stop running from the only reality we've got.


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