Tuesday’s midterm election results appeared to deliver a strong message of discontent to the young Obama administration. With Republicans gaining control of the House of Representatives and closing the gap in the Senate, many analysts saw the election as a rebuke of the Democratic agenda of the last two years. Perhaps the highest-profile of those policies was the Patient Protection and Affordable Care Act, the product of the epic legislative battle over health care reform. Though many of the PPACA changes have yet to be activated, its opposition has loudly and repeatedly warned that the reforms will bring rationing of health care for the American public.
That’s a false bogeyman because rationing is already here, according to a commentary by the University of Chicago’s David Meltzer in last week’s Journal of the American Medical Association. Though the word “rationing” brings to mind making do with scarce resources during wartime, the term applies to any time a good or service is divorced from the economic forces of supply and demand. With the influence of government subsidies, private insurance companies, and managed care, the American health care system has long been subject to rationing.
“Attempts to resist change using the specter of rationing are not reasonable because rationing already exists and is inevitable,” Meltzer, an associate professor of medicine and economics, writes with Allan Detsky of the University of Toronto.
Because each individual’s personal demand for health care is unpredictable – a person could go the next year without needing to see a doctor, or get in a serious car accident tomorrow – insurance companies (and government programs such as Medicaid and Medicare) play the role of mediators, evening out the cost and lowering the risk. But that role gives insurers the power to make decisions about what care is appropriate and necessary, which may include the ability to ration health care through denial of coverage. Because a patient can pay for the procedure themselves, it’s not quite the same as the wartime rationing of goods, but when an unapproved procedure can run hundreds of thousands of dollars, the result may be no different.
The real debate then is over who should be making decisions about health care rationing: profit-driven private insurers, or politically-prone government officials, the authors write.
“I think it’s silly to talk about rationing without more subtlety,” Meltzer told ScienceLife in a separate interview. “We should absolutely have a debate about rationing, but it’s not a debate about whether, it’s a debate about how.”
To illustrate how hard it is to have such discussions, the authors recommend running a Google search on “mammography” and “rationing.” There you’ll find several heated articles, from sources such as the Wall Street Journal and Fox News, accusing the administration of rationing the procedure used for breast cancer screening. The inspiration for such vitriol was a heavily-researched report from the U.S. Preventive Services Task Force, which found that false positives and cost outweighed the benefits of mammograms in younger, low-risk populations of women. The recommendation may have pushed insurance coverage of the procedure and health care costs in a more rational direction – had it not been rapidly blocked by a Congressional amendment due to public pressure.
What happened? Meltzer thinks it was a failure by the government to communicate clearly to the public about the balance between the benefits, consequences, and costs of the screening procedure. That mistake allowed health care reform opponents to sensationalize the recommendations as a harbinger of the rationing to come under “Obamacare,” seizing control of the media dialogue.
“Rather than elevating the debate it lowered it, and that’s a really slow way to make progress – if you make it at all,” Meltzer said. “The thing that’s most concerning is that we need to make progress soon, we don’t have much more time to deal with this problem. We are already spending as much money as we have on this and more, and it’s hurting us in all sorts of ways.”
Through their commentary, Meltzer said he and Detsky hope to reach physicians and the public to educate them about the true current status of health care rationing in the United States, so that the reform debate can be more constructive. Though “such public discussion will not be easy at this time because US politics is currently so polarized,” they write:
“It is critical that Americans learn that rationing currently exists and is inevitable and focus their thinking on how its vagaries are best minimized, rather than use the word to instill fear.”
Meltzer DO, & Detsky AS (2010). The Real Meaning of Rationing. JAMA : the journal of the American Medical Association PMID: 21041419