In the debate over how to fix the nation's health care system, one of the big worries is rationing.
"I don't think many Americans want to start having to wait in line [or] start getting government permission for procedures," Senate Republican Leader Mitch McConnell said last month on CBS's Face the Nation.
Americans might be justifiably nervous about losing control of their health care decisions, especially if they think government bureaucrats will be in charge. But some doctors and economists argue that, in effect, the U.S. health care system is already rationing, in the most unproductive ways.
"In America, we strictly ration health care. We've done it for years," says Dr. Arthur Kellermann, professor of emergency medicine and associate dean for health policy at Emory University School of Medicine. "But in contrast to other wealthy countries, we don't ration medical care on the basis of need or anticipated benefit. In this country, we mainly ration on the ability to pay. And that is especially evident when you examine the plight of the uninsured in the United States."
Groceries Or Medicine?
Kellermann still remembers the young mother of two who came into his emergency room more than 15 years ago, suffering from a hemorrhagic stroke.
"We worked for 90 minutes to save her life, but basically she had burst a blood vessel in her head. She didn't have a chance," he says. "She had no health insurance, and when the money got tight, she had to make a choice — she could either buy the groceries for her kids, or she was going to buy the three blood pressure medicines she had to take every day."
Sadly, Kellermann says, for less than the cost of that futile, 90-minute effort in the ER, the woman could have had all the blood pressure medication she needed for the rest of her life. It was not a government bureaucrat who decided she should forgo treatment until it was too late — it was her own lack of health insurance that led her to make that choice.
A few years ago, Kellermann served as co-chairman for an Institute of Medicine committee that looked at the kind of care people get when they don't have health insurance. On average, he found, the uninsured get only about half the care that people with insurance do, and they tend to wait longer and get sicker before seeing a doctor.
"The cost of staying home and feeling a lump grow in your breast, to feel a squeezing sensation become more and more evident with shorter and shorter walks every day, hoping beyond hope that it will go away — that's an incredibly expensive choice to make when, had you been able to get the care you needed early, it could have been quickly and easily and simply taken care of," he says.
It's not only the uninsured who are affected. Americans who do have health insurance tend to get a lot of procedures after they're sick — not because bureaucrats dictate that, but because that's what insurance and Medicare pay for.
"We do lots of joint replacements, back surgery, cardiovascular procedures, imaging procedures, and we do lots of those because they're well remunerated," says Dr. Elliott Fisher, director for population health and policy at Dartmouth's Institute for Health Policy and Clinical Practice.
Fisher says those high-cost services are not necessarily the best way to improve people's health. And as the cost of providing those services rises, insurance companies often cut the very primary care that could keep people healthier.
"I think there's a very real sense that we are rationing payments to primary care, and what that leads to is poor care. It leads to five-minute visits that many patients are experiencing," Fisher says. "Many primary-care physicians feel like hamsters running on a wheel. And they have to run harder each time Medicare or the private payers cut their fees."
Rationing is not limited to the health care industry. No other country devotes as much of its economy to health care as the United States. While Americans might not think of that as a choice, it means they have less to spend on everything else. Government payments for health care come at the expense of schools, roads and other services. The extra money that employers have to pay for rising health insurance premiums is money they cannot put into workers' paychecks.
"No worker gets to say, 'You know what, make my premium $1,000 lower by getting me a more efficient health insurance package, and at the same time, give me $1,000 more in take-home pay,' " says Harvard economist Katherine Baicker, who has studied the impact of rising health care costs on employee compensation.
So while there is no government rationing board handing out coupon books for heart surgeries, more and more of the nation's resources are being gobbled up by health care, often with little choice for individuals, and often in ways that no sensible person would choose.