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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 made news recently, 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.

David Katz, MD, MPH, FACPM, FACP, is the founding (1998) director of Yale University’s Prevention Research Center. This piece first appeared at The Huffington Post.

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27 Responses for “Rational Rationing vs. Irrational Rationing”

  1. Peter1 says:

    Capping is something private insurance also does, yet we don’t seem to discuss the appropriateness of it in the private sector. Delivering care based on a variety of individual factors, not related to “capping”, and also based on triage is the best way to determine who gets what care in a universal system.

    The lunacy of capping for spending control is it denies (rations) care to the poor(er) but guarantees care, no matter how unnecessary, to wealthier individuals, while not controlling costs.

    Applying caps to care without applying caps to costs is doubly offensive and will use up your cap limit much faster.

  2. bev M.D. says:

    I agree that rationing has always occurred, but a larger current problem IMO is rampant waste. Much waste can be eliminated in our health care ‘system’ before we even get to rationing. But it’s politically more advantageous for hospitals to talk about rationing whenever health care costs are to be limited.

  3. How about counting our “finite resources” and their distribution throughout the system, before we decide that that we don’t have enough of them to share with the poor?

    As long as health care dollars are extracted for profit, decadent compensation and wasted because of sheer laziness of all involved, you may be able to make rationing rational, but it won’t be just and it won’t be moral.

    • MD as HELL says:

      Quit treating “the Poor” like pets, Margalit.

      • I have pets at home. I decide when they’re good dogs. I decide when they get food. I decide when they get medical care. I decide how much medical care they get and I decide when it’s time to stop wasting “finite resources” on them and I get to rationalize all my decisions. They decide nothing.
        Who’s treating who as pets?

        • DeterminedMD says:

          As soon as someone used the word “finite” and health care in the same sentence or paragraph, I knew you would comment.

          Does the Secret Service know of your printing presses, ma’am?

          Just kidding, Big Brother of the Net!

          • No need for printing presses.
            You were born with an infinite supply of what is needed to care for others…..
            Not kidding at all… :-)

          • DeterminedMD says:

            Hilarious, simply hilarious. There is no comedy when someone continuously claims there are no finite resources in health care. Which you have done throughout my engagements with you.

            And every care provider has a finite ability to care, just ask Dr Lamberts.

            Again, need a sarcastic font! The Big Brother comment directed to any who troll the net looking for alleged signs of trouble. You doubt my concerns to this, at sites talking about health care?

            The author of the post is on the mark, rationing has and will always be.

          • You know Dr. D, it would be much more fun conversing with you if were a bit less “determined” to ascribe to others views you disagree with.

            “finite resources” is the new battle cry of the republic, right up there with “patient centered”. Of course resources are finite. Everything is finite except may be the universe itself. So what?

            The question is whether resources are adequate, not finite or not finite. And you cannot say that resources are inadequate, ergo we must ration them, just because the entitled few insist on arbitrarily and selfishly apportioning to themselves a huge piece of the pie before anyone else is allowed at the table. The crumbs are indeed inadequate.
            Resources are more than adequate, albeit finite in a cosmic sort of way, if everybody is allowed a fair share.

          • DeterminedMD says:

            Fun, the premise of the dialogue regarding the state of health care and those who want to control it is to be fun? No, never my agenda overall, having a laugh over something floridly foolish or idiotic, yes, I would participate then. Here, nah, not with the hell bent partisan push to maintain a status woer with time.

            Resources are adequate if everyone is given a fair share. You really believe that comment you ended with? If everyone needed an Ace bandage, you really believe everyone will get one, in a fair world?

            Well, the world is NOT fair, there are not an endless supply of bandages, and, why should everyone get one irregardless of why they need it? Again, per my point about smokers, this is 2012, we all know that tobacco use is only a detriment to health, so why should we as a society give smokers who refuse to honestly make an effort to quit have full court access to health care service?

            That is a third rail issue for this group here, isn’t it?!

          • You only need a little over 7 billion Ace bandages to satisfy the need of the entire globe. You do not need an “endless” supply. 7 billion is a “finite” number.
            As to smokers, that doesn’t have as much to do with infinity or lack thereof as it has to do with reaping what you sow, or some other “personal responsibility” type of thing, doesn’t it?

            Re: fun – I enjoy a good conversation, particularly with someone that disagrees with me. It’s educational and education is fun.

          • DeterminedMD says:

            7 billion Ace bandages. What is your point?! To heal us all to experience peace on earth, end starvation, and put a cell phone in every one’s hands? Gimme a break! You’ve already had yours. From reality. Good luck with your mission.

  4. mark says:

    Dr Katz

    What does this statement of yours mean? What, specifically, would you invest in?
    “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?”

    • Peter1 says:

      Mark, some of those “investments” are changing harmful tax policies.

      Taxpayers subsidize corn (and soybeans) which subsidizes many of our harmful foods such as meat and HFCS. We recognize that sugar is harmful yet we don’t tax sugar in foods like we tax tobacco. We could transfer subsidies to fresh fruit and vegetables as well as target tax policy to help pay for the health effects of too much sugar, fat and calories. We could also start re-funding physical education in the schools.

      The culture of tobacco acceptance has changed over 20 years or more because of taxes and smoke free legislation. The culture of food could also be changed which would reduce obesity, diabetes, heart disease, etc.

      • mark says:

        Thanks for clarifying. Another question from your post:
        ” 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…”
        I thought your mention of education was interesting. Since we have doubled per capita expenditures (adjusted for inflation) on K-12 over the past 40 years and college costs have increased at a greater pace than even medical costs during that period and from every measure we have educational results have not improved would you propose this as an area we can ration and cost cap after we tackle healthcare? Seems like we’re paying way too much money for the results we’re getting.

      • mark says:

        Further question; What does “target tax policy to help pay for the health effects of too much sugar, fat and calories”? You already mentioned taxing sugar in foods and using those revenues as subsidies for “good” food. What, in addition to these taxes are you thinking about?

  5. Dennis Byron says:

    This is completely wrong in terms of what it says about Massachusetts. Almost every piece of misinformation about Massachusetts in this article can be countered with publicly available information from the State of Massachusetts. (As for the rest of the nonsense, it doesn’t apply to Massachusetts so why he began this article with Massachusetts I don’t know.)

    The author says

    “In 2008, Massachusetts released results of its initiative requiring virtually all of its citizens to acquire health insurance…”

    The above is just oddly worded (perhaps the author is not a native English speaker?). There was no initiative. It was a law passed in 2006, not 2008

    The author says

    ” nearly three-quarters of Massachusetts’ 600,000 formerly uninsured acquired health insurance”

    there were only about 400,000 uninsured in Massachusetts prior to the law being passed (7%, see U.S. Census Bureau)

    The author says

    “most of (newly insured after 2006 received) private insurance that did not run up the tab for taxpayers.”

    Totally false. Almost all the newly insured received free Medicaid or highly subsidized RomneyCare (see any recent Quarterly Key Indicators Report from Massachusetts Department of Healthcare Finance and Policy)

    The author says

    “The use of hospitals and emergency rooms for primary care fell dramatically, translating into an annual savings of nearly $70 million.”

    Just not true. All kinds of academic research says the opposite relative to ERs including material on the DHCFP web site from June 2011. And I have never seen a dollar amount attached to any of it (who could one know?) and I suspect the author is thinking of the money that the state owes hospitals for free care but has not appropriated. (See any report on DHCFP concerning Health Safety Net)

    The author says

    “Massachusetts is… passing legislation that aims to impose a cap on overall health care spending.”

    One might ask why if the 2006 healthcare reform was so successful as described above

    The author says

    “That ambition implies, even if it doesn’t quite manage to say, a very provocative word: rationing.”

    Actually no one is contemplating rationing in Massachusetts as described here. It may happen seconarily as a result of bankrupt hospitals and doctors that cannot get market prices for their services moving to other states. But there is no Massachusetts panel like the national death panel proposed. Doctors and hospitals have to simply tell the state how they are going to lower their costs IF the costs exceed a certain limit and then some years-long quasijudicial process will ensue if the doctors or hospitals do not lower their costs.

    • SteveH says:

      Just to start with the uninsured in Massachusetts: In 2006 over 10% of the non-elderly population was uninsured. That’s 600,000 people.

      Second, “But there is no Massachusetts panel like the national death panel proposed.”

      There is no proposed national death panel.

      • Dennis Byron says:

        SteveH

        As I said in my first paragraph the source for the data I am referencing is the state of Massachusetts (Department of Healthcare Financing and Policy). I should not have put U.S. Census in parenthesis relative to number of uninsured. My source was the State of Massachusetts. The differences which have never been reconciled are described here (see http://blog.hcfama.org/2006/08/29/how-many-uninsured-in-massachusetts/)

        The key point is that all the NET NEW insured were at heavy government expense, either Medicaid or free RomneyCare or a small amount of heavily subsidized RomneyCare. The author’s statement that it was not on the taxpayer’s tab is false.

        As for death panel, you say to-may-toe and I’ll say toe-mah-toe. The key point is that we don’t have one here so why the author built a rationing argument around Massachusetts data makes no sense to me.

  6. mark says:

    Another question for you. Since rationing implies a fixed amount of care will be available and there are clearly areas where you want to increase the available amount of care, what do you see as the opportunities to reduce available care and what would be the criteria for doing so?

  7. MD as HELL says:

    “We” should spend nothing on healthcare. There is no upside to it.

  8. Chris Wasden says:

    All healthcare is ALWAYS rationed. It is either rationed through price or through government fiat. So the central issue isn’t whether or not healthcare is rationed, but who does it and how.

    When price is the mechanism for rationing then we leave it up to those with the resources to pay to make the decision. In such a system you get differentiation in services and products at various price points to meet customer and market needs. This drive creativity and innovation, and as we have seen around the world in the past century, the greatest increase in human wealth, productivity, and prosperity in the history of the world.

    When government provides the rationing, you then get subjected to arbitrary decisions made by people who are politically motivated to support and sustain the status quo. You get very little creativity and innovation. You get structural rigidity of old ways of doing things and costs tend to increase. What I have just described here is our U.S. school system as well as our healthcare system.

    Now many might say, “but what about the poor that can’t afford the care of the wealthy or lack the intellect to understand what they should do?” There are always ways to address this that continues to let Price be the rationing mechanisms. Indeed, Europe is talking about moving to such a system where they will provide everyone a fixed amount of money to pay for their healthcare needs as well as a catastrophic risk policy and then let them decide how they want to spend their healthcare dollars. In the U.S. this is the role that HSAs are now playing.

    As an employee on an HSA I can tell you that we make radically different healthcare decisions today when we know it is our own money at risk.

    • DeterminedMD says:

      “As an employee on an HSA I can tell you that we make radically different healthcare decisions today when we know it is our own money at risk.”

      and there it is. Betcha Nancy P and Harry R say the same damn thing when the TVs aren’t recording them at the Capitol.

  9. Great post! It remains a great mystery to me how some can claim with a straight face that health is not rationed today. As you point out, it is rationed today in three ways, and it is very evident.

    1) Do you have insurance? If yes – you get care. If no – care is rationed.

    2) If you have insurance, is this a covered benefit. If yes – you get care. If no – care is rationed.

    3) Have you reached your lifetime or annual max? If no – you get care. If yes – care is rationed.

    Tell me, how is this not rationing?

    In my humble opinion, it is fairly evident that “Obama Care” has done more to reduce rationing by eliminating lifetime and annual limits and extending coverage than anything else. Am I wrong?

  10. Chris Wasden says:

    The issue is who and how do you want the rationing done. Do you want the government doing it based upon averages, political lobbying, and non-financial and non-clinical criteria, or do you want to be the one doing the rationing with your own money and/or money provided by the government to use where the only thing that matters to you is value and outcomes. I would much prefer the latter. That is why I think healthcare reform as currently outlined is not the preferred form of rationing. It is rationing in the name of care and economics that will achieve neither.

  11. John Ballard says:

    Call it rationing or anything else you like, but as long as health care is treated as a commodity instead of a right, American health care will never measure up to the standards that are being set in the rest of the world who treat it as a right, often in places working with very meager resources.

    The data will show, of course, that poor countries get worse outcomes than rich ones. Well, duh! Data is the new religion, you know. But that’s like arguing that riding in wagons is slower than riding in cars. It’s a stupid and irrational argument. America has no excuse for not being at the top of every outcomes comparison chart in the world when it comes to the health of our citizens.

    A comment left at another post by Dr. Jha prodded me to put together another blog post which may interest readers here.

    http://hootsnewplace.blogspot.com/2014/03/hcr-patient-centered-or-profit-centered.html

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