A Rational Look At Rationing

The Oregon health care plan recently approved by Health and Human Services Secretary Donna E. Shalala has recevied less attention than the more prominent idea of managed compeptition, even though it makes more sense and has been more fully worked out.

The plan takes a simple and direct approach to health care. A panel of experts ranked 700 medical procedures according to their cost and benefits. In order to close the health care gap, Oregon decided to reallocate its Medicaid funds to cover all state residents below the poverty line. The catch is that the program would pay only for the 588 procedures rated most important. It would elimate the remaining procedures, considered too expensive and no effective enough to justify their added price: from life support for hopelessly premature babies to treatment for conditions that clear up on their own, like the common cold. It insures that everyone will receive care for ailments that are curable.

The Clinton administration should at the very least offer the Oregon plan to all Americans below the poverty line, replacing the less-inclusive Medicaid. It should also use its pay-or-play formula to require businesses to pay a tax for employees who wind up in the rationing system or to provide their own coverage that meets federal standards.

Rationing would include the 37 million currently uninsured Americans in the regular health care system. It would control costs better than slapping artificial price limits on drug companies or doctors. Medical expertise is expensive for a reason. It takes a lot of effort, education, intelligence and money to become a doctor. Drug costs reflect the steep expense of research. Price controls would hurt the quality of care in America by reducing the incentive for innovation.

Rationing on a wide scale, however, will not be seriously considered as a solution to the health care crisis until Americans become less squeamish about making qualitative judgements that affect human life.

Ironically, opposition to rationing focuses not on limits on common but useless procedures such as treatment for a cold but on those costly and ineffective procedures that involve grave illness.

Opponents claim that to deny liver transplants to victims of liver cancer, an extremely expensive and unrewarding procedure, or life support to anencehpalic infants--that is, infants born with no brain, who have absolutely no prognosis for recovery--is to put a price on human life.

Such an argument assumes that we don't already make any such cost-benefit calculations. Theoretically, the government could pay for preventative appendectomies, and monthly MRI exams for everyone and save a few lives. But it does not, recognizing that the cost is not justifiable.

It is nothing short of indulgent sentimentality to insist on unlimited treatment when there are 37 million Americans with no health insurance and no access to simple, effective care. Every so often, the case of an anencephalic baby who is to be taken off life support gets publicity. This inevitably occasions the grotesque spectacle of right-to-life zealots trying to adopt the baby to prove that it is worth millions of dollars to treat such a hopeless case. To them, I say this: offer to pay for the care, too. They should save their abundant crocodile tears for the less glamorous, but all-too-common case of an uninsured youngster who must fear a simple sore throat or broken limb.

Some opponents appeal to a putative "right to health care." But to understand this idea as an entitlement to medical treatment unlimited in cost and scope is unworkable and absurd. Fundamental rights, like that of free speech, are designed to prevent the government from unjustly restricting behavior.

In this sense there is a right to health care: The government cannot stop people from spending as much money as they want on whatever treatments they can persuade doctors to prescribe them. Nor can it prevent people from paying private insurance companies to do the same. But to those sensible citizens who recognize the futility and absurdity of such a course, the government should offer equally sensible health care rationing.

The medical community has become a priesthood in white coats. And like any priesthood, it has a tendency to attach to dogma. In this case, the dogma declares that it is always necessary to do something--anything--for a patient, even when no profitable treatment is available. Thus doctors will often perfunctorily prescribe some treatment for mononucleosis, though the illness will pass on its own and in its own time. Doctors often pursue unbelievably expensive courses of treatment in cases where there is no reasonable prognosis for recovery.

We thus witness a tragic irony: Gravely ill patients fight their doctors not to treat them, not to spend millions on a futile battle that offers them only the prospect of a Pyrrhic victory. Patients, understanding what blind dogma won't recognize, arm themselves with do-not-resuscitate orders and living wills.

At the same time we witness people fighting to be treated in inner city emergency rooms. The stakes for them are a sure cure and restored quality of life. This situation is sad, unfair, and totally irrational. Rationing is its solution.

Resources should be focused on minimum care for everyone, not maximum care for few.