Health Care

'Rationing' Puts Fear Into Health Care Debate

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The word "rationing" has been tossed around quite a bit in the current debate on overhauling health care. But what does it mean? Atul Gawande, a surgeon in Boston who works at Brigham and Women's Hospital and the Dana Farber Cancer Institute, talks with Ari Shapiro about what rationing means, and how it could impact the debate over health care.


Rationing is a word that gets thrown around a lot in the debate over health care. We've called Atul Gawande to explain exactly what the word means and how it fits into this dialogue. He's a writer for the New Yorker and a surgeon in Boston who works at Brigham and Women's Hospital in the Dana Farber Cancer Institute. Welcome to the program.

Dr. ATUL GAWANDE (Writer, New Yorker, Surgeon, Brigham and Women's Hospital, Dana Farber Cancer Institute): Thanks for having me on.

SHAPIRO: Well, let's start with the definition. What does rationing mean in the context of health care?

Dr. GAWANDE: On the simplest level, it's a fixed allowance of health care. This is all you get. And that's the specter we have put in front of us when we talk about rationing in the context of health reform. We fear that it'll become a fixed allowance of care.

SHAPIRO: The fear being that I need a CT scan but because I've already had as much health care as I'm allowed or because the CT scans for that month have been taken already, I just don't get the medical care that I need.

Dr. GAWANDE: That's right. And it's never been the way American care works. It's not going to be the way American care works. Nonetheless, it is such a frightening prospect - that you would have something taken away that you might need - it can be a death blow for efforts to reform care.

SHAPIRO: You have talked about rationing care versus rational care. What do you mean when you say rational care?

Dr. GAWANDE: If we go back to the CT scan example: we know that doing 62 million scans every year for a population of 300 million, is not just unnecessary and wasteful, but it's dangerous. It's producing tens of thousands of cancers. Many of these CT scans are not necessary.

Rationing care would be to say, well, we're only going to do 50 million scans next year, and if you're scan number 50-million-one…

SHAPIRO: You're out of luck.

Dr. GAWANDE: …too bad, you're out of luck. Rational care would be to recognize we are doing, you know, head scans for people with ordinary headaches that we already have good evidence and guidelines indicating that it's not smart to do that scan for folks. And it would be to have physicians and patients who work together in sensible ways to knock that down.

SHAPIRO: And if the patient comes back and says to the physician and the radiologist, I don't care; I want the scan, do they get it?

Dr. GAWANDE: Well, on some level, yes. It is part of the art and practice of medicine that you have folks who come in who may want something that's not that smart for them. It rarely works to put your foot down and say, you know, get out of my office, you're not having it.

(Soundbite of laughter)

Dr. GAWANDE: What often does is to walk through the risks and the benefits and why you think it's not such a great idea to do this.

SHAPIRO: So, for people around the country who are trying to figure out how an influx of 46 million currently uninsured people into the health care system could possibly not reduce the amount of health care available to those who are already insured, give me an explainer. How does that work?

Dr. GAWANDE: Well, the short answer is there will be some transition time. Almost every bill that I've seen - and I don't know all the details - but they're talking about four to five years at a minimum to begin transitioning those people in.

Our real struggle going forward is that the number of elderly are going to double over the next 20 years or so. The number of geriatricians we're producing is actually dropping at a time when we need to be producing more geriatricians. We need more geriatric care nurses. That line of work is there, no matter whether we do reform or not.

In fact, it will be worse if we have not reformed the system to improve our ability to cover everybody and be more sensible about how we spend our resources.

SHAPIRO: You've talked about the way that physicians working with their patients in good faith can streamline the system. How much faith do you have in the ability of the government, of lawmakers, to create policies that mandate that kind of behavior?

Dr. GAWANDE: I don't even know how to grade it. I might say, you know, on a scale of one to ten, I might have, you know, a five for confidence. But here's the situation and the way I think about it: it's like having a patient who has a 50 percent chance of death if we don't do something. You know, we're in a situation where Medicare will go bankrupt in 2017, in eight years, if we are not acting here.

My greatest fear is doing nothing. And this is going to be a 10, 15, 20 year project that if we don't start down this road, we will be in real trouble.

So, do I trust we are going to fix it on the first go? Absolutely not. Do I trust that we'll be moving in the direction that we need to be in, a good direction? I do, actually. I have trust in our ability as a country to self-correct, to be able to progress forward.

SHAPIRO: Dr. Atul Gawande is a surgeon and he writes for the New Yorker magazine. Thanks a lot.

Dr. GAWANDE: And thank you.

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