Weekend Reading: The “R” Word in the Health Care Debate

Posted on July 17, 2009


One of the most heated debates surrounding health care reform has to do with the “R-word:” rationing. The term sends chills down the spines of many; images of desperate people waiting in line for medical procedures motivate many an activist to oppose reforms to the U.S. health care system with cries of “socialized medicine” and “don’t let government bureaucrats make decisions about your health care.” A New York Times Magazine article by Peter Singer (to be published on Sunday, but posted on the Web earlier this week), brings a far more nuanced approach to the issue, and is definitely highly recommended weekend reading.

The article’s title – Why We Must Ration Health Care – leaves little doubt as to the author’s position. One of Singer’s main points is that, despite what we may think, health care today is already rationed implicitly, mostly by price: “you get what you, or your employer, can afford to insure you for.” He argues that we should be explicitly rationing health care:

Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?

One of the ways Singer points to is what is done in Britain, where the National Institute for Health and Clinical Excellence (NICE) provides guidance to that country’s National Health Service on which treatments should be covered. NICE conducts the sort of “comparative effectiveness” research that has been part of the health care reform debate in this country and is opposed by many in the health care industry. It is quite easy for discussion on the topic to become emotional, as arguments break out about how to assign a dollar value to a life, and who should be responsible for doing so.

The fundamental challenge in reforming health care is that the debate takes place at the intersection of two areas that most people are uncomfortable comingling: morals and economics. And we’re not talking about just any moral question, but fundamental questions about life and death. Singer explores the question in a measured and reasoned way and, in the end, comes up with the outlines of a policy idea that sounds quite reasonable: universal coverage with optional, private insurance. As Singer writes,

Rationing public health care limits free choice if private health insurance is prohibited. But many countries combine free national health insurance with optional private insurance. . . . Every American will have a right to a good standard of health care, but no one will have a right to unrationed health care. Those who opt for unrationed health care will know exactly how much it costs them.

But, as usual, the devil is in the details. How, as a society, will we define a “good standard of health care?” And how will we decide how much we, as a society, are willing to pay for that standard? What about the role of lifestyle choices and personal responsibility – should smokers (or overeaters, or non-exercisers) somehow be compelled to pay for the extra health care costs that result from their choices? Just a few of the difficult questions that will be debated in the coming months and years.