Preventive Medicine Column
Dr. David L. Katz
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 ¾ of Massachusetts’ 600,000 formerly uninsured acquired coverage. 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 healthcare 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.
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 US 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. 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 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% 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. 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. Rationing is inevitable, but whether rational or irrational is our choice. 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.
Dr. David L. Katz; www.davidkatzmd.com