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Guest Opinion: Rationing already present in health-care system

BY DOYLE McMANUS - GUEST OPINION | OCTOBER 12, 2009 7:20 AM

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Late last month, as the Senate Finance Committee labored to produce its version of a health-care bill, the Republican whip, Sen. Jon Kyl of Arizona, renewed an old warning. If the federal government intervenes to hold health-care costs down, he said, the result would be something nobody wants: rationing.

Kyl is mostly right. If government agencies (or insurance companies or individuals) limit the price they are willing to pay for a service, then providers probably would provide less of it. To Kyl, that’s rationing. But it’s also sound economics.

Both Republicans and Democrats are in denial on this point. Republicans pretend that our current system doesn’t stop anyone from getting all the care they need. Democrats pretend that efforts to control costs won’t limit medical choices and treatment. But most real-world consumers know better: There is no free lunch. As medical technology improves, there’s no way all of us can have all the high-end care we want — unless we are willing to pay for it.

At least one conservative Republican, Rep. Paul Ryan of Wisconsin, acknowledges what this debate is really about.

“Rationing occurs now,” he said recently. “The question is: Who does it? Is it the government, or is it the patient [and] the doctor along with the insurance?”

As Ryan said, we already have rationing — and we have for many years, even when Republicans controlled Congress.

It’s true that we don’t ration health-care directly. If you’re willing to pay cash, you can buy all the health care you want — at ruinous retail prices.

But we do ration health care indirectly, in two ways:

First, we ration health insurance. We make affordable insurance available to some people, but not to others.

Second, our insurers — insurance companies or the government, if you’re on Medicare or Medicaid — ration what they’ll pay for. They’ll reimburse some costs but not others.

These things aren’t “rationing” in the old-fashioned sense, but as far as patients are concerned (to quote Kyl), “it’s the same result.”

The Democrats’ proposals would make affordable insurance available to millions more people, if not to everyone. So one major form of rationing — the rationing of health insurance — would be relieved.

As for making decisions about what care is paid for and at what price — the indirect form of rationing Kyl warned about — that’s a stickier point. The Democrats mostly kick the can down the road. Their bills set up a council on “comparative effectiveness research” to study which forms of care are cost-effective and which are wasteful, but they insist the board won’t have power to deny payment for inefficient practices — at least, not now. Republicans are right to warn that the board might grow teeth: If it finds that a treatment produces negligible results at high cost, it will push to stop paying for it.

So the bad news is: Yes, there will be rationing. The good news: Whether we realize it or not, most of us are used to it already.

Doyle McManus is a syndicated columnist. A version of this commentary originally appeared in Sunday’s Los Angeles Times.


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