Rationing One Way Or Another

Andrew Sullivan —  Apr 8 2011 @ 10:29am


Here’s one way of looking at the crisis in Medicare and, indeed, private health insurance. The diagnostic advances, pharmaceutical innovations, and bio-technology now available for doctors have transformed the very meaning of what constitutes health. Instead of being a limited number of options for a limited number of diseases, the sky is now the limit. This, of course, is a wonderful thing (without it, I would be dead by now) but it also means higher costs as health shifts from rescuing people from a few diseases to offering people any number of treatments to prevent illness, extend life and promote health. I can’t see any way around this cost. If we want to reduce this giant suck from the rest of the working economy, there are two options: have a government body decide which treatments can be afforded and which cannot; or have patients ration themselves by price. That is one core difference between the Democratic approach and the Republican one. CATO’s Michael Tanner puts it simply enough: “Rationing is going to go on within the Medicare system. It’s a fact of life” given financial constraints, he said. “The question’s going to be, is that decision going to be made by government and imposed top down under the current system? Ryan wants to shift that responsibility to individuals and from the bottom up.” Case in point: The Medicare subsidies proposed by Ryan would barely meet elementary health needs of seniors, and they would have to supplement them with their own savings if they wanted better care. The alternative would be not unlike what happens in Britain, where rationing occurs by waiting lists. My own view is that central government diktat on these things is more likely to provoke anger and even more heated debates and paralysis than now.

Every politician seeking to rein in costs will be called a callous accessory to murder (just take some time to see how the British parliament spends hours debating abstruse medical procedures and expenditures best left to doctors and patients). It will make “death panels” and “death traps” key parts of the political discourse.

But it also seems to me that empowering patients to choose from a variety of health plans should also include empowering them to make end-of-life decisions ahead of time. So much healthcare expenditure occurs by keeping people alive for a few more final days in an ICU. If only a fraction of Medicare recipients were asked – just asked – to consider a living will, and made one, we could move those huge and, in some cases, needless expenditures toward preventive care or better options for all seniors. But Paul Ryan will have none of that. And by abolishing Obamacare, he would also kill off several important cost-control pilot schemes. There’s a lot of good in his proposal, but also a lot of partisan posturing and bullshit math.

(Photo: Hospice volunteers caress the hands of terminally ill patient Annabelle Martin, 92, as her health quickly declined at the Hospice of Saint John on September 1, 2009 in Lakewood, Colorado. The non-profit hospice, which serves on average 200 people at a time, is the second oldest hospice in the United States. The hospice accepts patients regardless of their ability to pay, although most are covered by Medicare or Medicaid. End of life care has become a contentious issue in the current national debate on health care reform. By John Moore/Getty Images.)