health care rationing - making rationing compatible with the myth

On the surface it might seem impossible to conduct widespread rationing in a vast industry like health care, which consumes more than 13% of the GDP and directly affects the lives of most citizens at one time or another, and to do it covertly, in secret. Wouldn’t the rationing of such a highly visible commodity be apparent to everybody?

Actually, it is quite apparent if you look for it. It’s just that all of us have more-or-less agreed not to look.

To a very large extent, those who are doing the rationing – the doctors, the hospitals, the HMOs, the pharmaceutical houses, the biotechnology companies, the scientists, and the governmental agencies – subscribe to the same myth of American health care as the general public. They carry out their activities openly and proudly. Most, in fact, would find the very notion of rationing to be repugnant, and would no doubt take great offense to hear they are being accused of doing so.

Thus, covert rationing is not the result of some vast conspiracy to deceive the American public. (In fact, I don't believe that large, sustained conspiracies - anything more complicated than, say, cheating at bridge - are even possible.)

The covert rationing of health care is, in fact, a textbook case of subconscious collusion. In the case of health care rationing, subconscious collusion operates thusly: First, the irresistible economic forces that require rationing line up to foster a certain attitude, a certain way of looking at things. Then, within every entity in the health care system, those who embrace such an attitude become ascendant, not by conspiracy or plot, but by natural market forces.

That certain correct attitude, the new “right stuff,” is defined by the ability to suggest actions that have the effect of limiting health care services, while couching those suggestions in the language of the American health care myth. In essence, this kind of thinking allows organizations to direct the rationing of health care, while at the same time advancing the notion that rationing is unnecessary.

Note that there is surprisingly little hypocrisy under this scenario. While undoubtedly some of the individuals who are directing the rationing behavior understand exactly what they are doing, most continue to subscribe to the myth of “no limits.” Most honestly believe (or at least, want very badly to believe) that their actions are not reducing useful services, that instead, they are reducing waste and improving the efficiency of the system. Those who do understand the true nature of their actions generally shield themselves from having to communicate that knowledge. They are more likely to become the quiet, private CEO’s whose spokespersons and PR directors (individuals who are entirely sincere about what they are telling the public) do their speaking for them.

So there is no conspiracy. The covert rationing of health care is conducted by a myriad of organizations, all acting quite independently, all simply responding to economic imperatives. The key for organizations that want to flourish within the health care system is to identify leaders who can respond both to the irresistible need to ration health care, and to the equally irresistible need to rationalize such behavior in terms acceptable to the rest of us. Those individuals, men and women of vision, are presently the Most Valuable Players in the health care system.

The enabling visions advanced by such individuals – visions that permit covert rationing activities to go forward openly, freely, and often profitably – can be categorized into two general schools of thought. We will be spending some time with both schools of thought in coming sections, and will be getting to know them well. A brief introduction for now will suffice.

Next: Clintonians v. Gekkonians

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