health care rationing - consequences of covert rationing

We’ve agreed that rationing in any form is bad. But, while there’s no doubt that devising a fair system of open rationing would be difficult and painful, the ultimate consequences of covert rationing are even more terrible.

Consider just the most obvious result when health care has to be rationed tacitly. Human nature being what it is, the special interests (the doctors, hospitals, insurers, the biomedical industry, and the government) proclaim, apparently sincerely, that the changes in health care occurring today are good, and represent their single-minded efforts to become more efficient, patient-oriented and quality-driven. Meanwhile (again, human nature being what it is) those same special interests become embroiled in a bloody competition, between and among themselves, for what they realize is a limited health care dollar.

This competition is incredibly fierce because it is driven not merely by greed, but perhaps more importantly by the threat to professional and corporate survival. Next to an all-consuming threat like this, the health care being provided to the general public (the entity for which the health care system ostensibly exists in the first place), becomes almost an afterthought. Consequently, that limited health care dollar, instead of being used to bring about the greatest good for the greatest number, ends up in the hands of whichever special interests are best at “playing the game.”

“Oh,” you may be thinking, “those evil special interests!” But before calling out the posse, consider the role you yourself play in all this ("you," that is, the well-informed health care consumer). For the sad fact is, covertly rationing health care simply wouldn’t be possible without your collusion as well, subconscious though it may be. Indeed, in the covert rationing scheme of things, you and those like you simply constitute another special interest.

To illustrate, assume for a moment that, having taken a long look at some of the goings on in the health care industry, you’ve come to smell a rat. Perhaps, let’s say, you’ve even begun to suspect there are forces within the health care system that have lined up to direct the limited health care dollar their own way, to the detriment of the general public. This being the case, what would you do? Would you cry foul, try to instigate change, attempt to stem the unfair influence of the special interests, and insist that limited funds be spent to do the greatest good for the greatest number? Perhaps. But by doing so, if you insisted that funds be spent evenly and fairly among the population, you might personally have a lot to lose. Even if you happen to be living under a managed care plan with particularly restrictive rules, for instance, you know that those rules can be bent for the occasional, vociferously savvy consumer in exchange for silence – silence that keeps the insurer from having to change the rules for the masses. So, as long as rationing remains covert, you personally have a very good chance of getting the health care you need, or, at least, that you think you need. It makes as much sense for educated, well-informed patients to silently collude with rationing as it does for their physicians or their insurance carriers.

A cynic might ask: if covert rationing is okay with the health care industry, okay with well-informed patients, and is truly (as opposed to tacitly) unnoticed by everybody else, why make a big deal about it?

The answer is, the covert rationing of health care is more than just selfish, unfair and deceptive; in the end it is highly destructive not only to each of us individually, but to our entire society.

For one thing, by pretending that we are not rationing (and indeed, that there is no need to ration), we are bequeathing to our children and grandchildren an enormous and highly destabilizing fiscal burden.

Even more important than the fiscal burden we are creating for our children is the political and social burden we are creating for them. For in order to keep the rationing of health care covert, we are engaged in a disastrous cascade of compromise and self-deception that threatens the basic underpinnings of not only our health care system, but also our American culture. Such self-deception can be recognized today in every aspect of health care: in the broad-based restructuring in the business side of health care; in the sweeping and stultifying changes in the legal and regulatory climate; in the design, justification, and interpretation of medical research; and ironically, in the growing call for expanded “patients’ rights.” These compromises will have destructive effects that range far beyond merely withholding useful health care from some of those who need it. Taken together, these compromises constitute a powerful attack on the most essential ideal of our American society, namely, the autonomy of the individual.

This ideal is never completely secure; it always requires a vigorous and ongoing defense. In fact, we have spent most of the 20^th century defending the rights of the individual over those of society. The defeat of fascism and of communism (two social orders that each awarded primacy to society, in the guise of the state), along with the nearly universal acceptance of the ethical principles embodied in the Nuremburg Code, was thought by many to have settled the question, once and for all, in favor of the individual. But this is a question that can never be answered once and for all.

This question is deeply challenged by the issue of health care rationing itself. For if we ration, whether overtly or covertly, we must withhold from individuals for the benefit of society. Under even the best of circumstances then, rationing of any kind poses a serious challenge to the notion of primacy of the individual.

But while it is at least possible to construct a system of open rationing that maintains the autonomy of the individual, such autonomy is always sacrificed under covert rationing. Covert rationing abandons the individual often as the very first step, and does so without any discussion whatsoever, and often without any realization as to what is being thrown away. If we lose the principle of individual autonomy, we lose everything that is inherently American. This is the ultimate price we pay as a society when we quietly, subconsciously collude with the covert rationing of health care.

It is ironic that our American health care myth, a myth that derives from our principled commitment to the primacy of the individual, leads us to actions that attack that first principle, and virtually guarantee its destruction. The destruction of the doctor-patient relationship is merely the earliest, most direct, and most personal manifestation of this attack.

Next: Section3: Health care 2000 - How it got this way

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