Why is the prioritization of health care and rationing such a third rail of health care reform? Individuals are continually forced every day to prioritize their own resources, deciding what to use them for and what to forego. The process couldn’t be more familiar.
Since our wants typically outrun our resources, we learn to make the choices and move on to the next ones. So why is the very idea of prioritizing and rationing health care resources so troubling and controversial?
Americans are deeply ambivalent and inconsistent about health care costs and rationing. On the one hand, many like to pretend that rationing does not take place, but on the other hand they fear being denied beneficial care, in particular payment by their health insurance plans for care they need.
Many say that we are a rich country and have no need to ration health care, but on the other hand they resist rising costs of health care, particularly when they result in greater out-of-pocket costs to them. Many say that life is precious and money should not enter into decisions about medical treatment, but on the other hand they resist the ever increasing proportion of both our national wealth and their own wealth that goes to health care. Many recognize the need to limit the use of some health care, but on the other hand resist those limits when they are applied to them or others about whom they care deeply.
Now these inconsistencies might simply reflect a perfectly common and understandable desire to have more of a valued good like health care, but not to pay more for it. For goods that we must purchase in a marketplace, we soon learn that this is not a desire that can be satisfied – if we want more, we must pay more, and so we must decide how much that is worth to us in comparison with other uses for our resources.
Most Americans, however, do not pay out of pocket the full, or even most, costs of the health care they receive. If insurance pays, it is hardly surprising that we do not support rationing which will have the effect of denying some health care to us.
Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefited by that good will not receive it. This allocation or rationing can take place by many means. The use of a market to distribute a good is one common way to ration it.
Most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity. Despite this widespread view, we remain the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it.
Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. The avoidance takes many forms. As already noted, a prominent one is just to deny that significant rationing takes place. When this denial becomes increasingly difficult to maintain in the face of the realities of the health care system, a typical alternative strategy is to condemn rationing as unjust or unethical and so to deny that it should take place.
If people widely believe that health care rationing does not take place, and that if it did it would be wrong, it is hardly surprising that we have not had a responsible public debate about when and how it should be done. But both of these beliefs that health care rationing does not take place, and that if it did it would be wrong, are false.
Perhaps it is inevitable that rationing must occur if others limit resources available to physicians to care for their patients, but many deny that resources should be limited in this way. This is a mistake, however, and it is important to understand why.
As long as there is some limit to the resources available for health care, health care will have to be allocated to those who need or want it – with not everyone getting all they need or want. Allocation in the face of scarcity is inevitable.
The only to avoid scarcity in the health sector would be to provide all services to all patients who are expected to benefit, no matter how small and uncertain the benefits, and no matter how high the costs. This is clearly impossible.
Everyone might benefit from having a private physician accompany us when we travel, or from unlimited resources for research for diseases that we have or have some chance of getting. Everyone may benefit from having an MRI on the very tiny chance that a brain tumor may be causing the headache they are experiencing. Yet none of this would be possible without enormous increases in health care costs.
More important, even if possible, none of it would be rational or desirable. To avoid scarcity by providing everyone with all care of any positive expected benefit would have tremendous opportunity costs.
We would have to devote enormous additional resources to health care that produced minimal benefits when we could have used them to produce vastly greater benefits elsewhere, such as in education or rebuilding the country’s infrastructure. Even within the health sector, trying to provide all beneficial care for some patients regardless of costs would inevitably prevent us from treating other patients who would benefit more.
So the only way of avoiding the need to ration health care would be irrational and undesirable. It would also be arguably unethical. We would have to use resources in a very inefficient manner producing far less by way of overall benefits for the population served than if we did ration care.
And since society has other ethical responsibilities to its citizens in areas such as personal and national security, education, and so forth, failing to ration health care would inevitably result in failing to meet these other ethical and political responsibilities and obligations. How to ration health care is the subject for another blog, but that it is and should be done is undeniable. Health policy analysts understand all this – the momentous task for health reform is to bring the public to understand and accept it.
Dan W. Brock, PhD, is Frances Glessner Lee Professor of Medical Ethics, and Director of the Division of Medical Ethics at the Harvard Medical School, where he also directs the University Program in Ethics and Health. He was a member of the Ethics Working Group of the Clinton Task Force on National Health Reform in 1993 and is an elected member of the Institute of Medicine. His most recent book is From Chance to Choice: Genetics and Justice (with Allen Buchanan, Norman Daniels and Daniel Wikler), and his main current research interests are in health care resource prioritization. This blog draws from his paper, “Health care Resource Prioritization and Rationing: Why is it so Difficult?” Social Research, 74, 1 (2007): 125–148. firstname.lastname@example.org; 617–432-5131.