Secret's Out -- Our Government Is Rationing Medical Care

There's some sad and shocking news for those who have been manning the ramparts in opposition to health reforms that would allow our government to ration medical care.

The rationing has already begun. Our crafty government has been imposing rules that determines who gets what care for decades. What we're talking about now can more honestly be seen as the end of that process rather than the beginning.

Today's real questions are whether the rationing system already operating should be expanded and can be used to yield improved results. Asking whether Americans will allow rationing is untimely and irrational. The answer is clear -- they already are. Efforts to avoid rationing entirely are a quixotic effort to close a barn door that's been open so long the hinges have rusted away.

In my continuing quest for truth, justice and transparency, here's an effort to strip away some of the veils cloaking this clandestine rationing. Consider these:

l. America's largest insurance plan, Medicare, pays for some procedures, but refuses payments for others or sets standards that must be met that help some patients while denying treatment to others. For instance, bariatric surgery for the obese is only available at selected institutions and only reimbursed when the patient has another weight-linked disease. I'm told private insurance plans make similar decisions.

2. A bureaucratic government agency known as the Food and Drug Administration decides what drugs can be sold in the United States. A delightful painkiller my South African friends recommended simply isn't available in the U.S.

3. Hospital emergency rooms are required to provide at least some treatment to stabilize the condition of those whose lives are at risk, but there's no similar mandate for chronic conditions. So motorcycle injuries are guaranteed treatment, but cancer isn't.

4. Most insurance plans are required to offer new moms a 48-hour hospital stay and the benefit expands to 96-hours if the baby is delivered via a cesarean section, but the federal government doesn't mandate a hospital option for heart attack victims.

5. My insurance plan, sponsored by my former employer, the American government, doesn't generally pay for abortion services. That decision was made in Congress by some of the very folks who today are most outspoken against rationing.

6. Really sick people who need an organ transplant are at the mercy of an allocation system backed by the government. Demands exceeds supply, so rationing is required to help decide who the lucky winners are.

In the absence of a health care fairy who will provide anything we want at a cost we can easily afford, there's a need to set priorities. Priorities is a polite word for rationing.

We used to have a simpler system in America. A half century ago, when there weren't near as many expensive cures as exist today, we had a much simpler system that was mostly based on money. Those who had a lot of it -- or good insurance -- enjoyed an all-you-can eat health care buffet.

And those who didn't, didn't. It was a simpler system. But no one I know suggests it was fairer. Ever since then we've been trying -- with more than a little success (something both sides of this debate seem strangely loathe to acknowledge) to come up with a better system.

Today's debate is simply the latest chapter, but it won't be the last one.

Rationing, it would seem, is here to stay. And its time for those who apparently missed the inaugural announcement to confront this long-established reality.

Comments

[johnashman]

Do we have any commentary on the fact that Obama's own physician thinks the plan is a failure?

From my angle, it just looks like a whole lot of bureaucracy with no serious benefit, the worst of all worlds.

I'm really surprised that Democrats aren't revolting against what appears to be a truly watered down plan.

Personally, I'd like to see the health insurance industry destroyed, but not for single payer, for 'infinite payer'. I'd also like to see much of the legal industry and bureaucracy and accounting industry destroyed as well. But it seems like that will all get a shot in the arm.

[Jim Jaffe - Huffpost Blogger]

As someone who used to work in the legislative sausage machine, I find it odd that people keep analyzing a "plan" that doesn't really exist yet -- and properly so. We have three bills from House committees that must be merged prior to a vote and at least two on the Senate side, including one -- from the Finance Committee -- which is very much a work in progress. It will be a major challenge to slice and dice and fit the pieces together in a way that is both workable and can win a majority, but there's ample time for that. Will there be a public plan? If so, how will it set rates? Where will we find the revenue to fund this program? These are big questions that don't begin to have answers yet. That's what the legislative and political processes are for and we're still in the early stages.

[johnashman]

True, but it seems to resemble sausage when people were ordering steak. It seems to me it's just a lot of unfunded mandates for business and tax payers. Obama's Doc thinks single payer is the only way. I know it isn't, but no one takes MSAs or MRSAs seriously, especially if it is the primary deductible on your taxes.

Have you looked at my MRSA plan (unfortunate acronym, I know)?

[wlhigh46]

Please check out the speeches and writings of Obama's close advisors Dr. Ezekiel Emmanuel and Dr. Sydney Blumenthal. They are of the opinion that the disabled and the elderly should not be guaranteed health care and that physicians have been taking the Hippocratic oath too seriously and that the first thing a doctor should ask when confronted with a medical problem is, "Is it worth the cost?". Check it out.

[Jim Jaffe - Huffpost Blogger]

no evidence of this appears in any of the bills under consideration in Congress. Certainly data on what medicare spends during the last two years of life raises this question of whether we're spending too much on terminal patients the expense of others. Again, it is a question of priorities.

[Sandy Goodman - Huffpost Blogger]

Thanks to Jim Jaffe for unmuddying the waters on a crucial aspect of the health care debate. He knows more about this subject than about 99 per cent of the folks who are writing about it, and attention ought to be paid to what he has to say.
That Obama's health care reform would suddenly bring rationing to a process that has had no rationing all of these years is the kind of transparently idiotic Republican nonsense that, unfortunately, we've had to get used to. Health care has long been rationed to the 47 million Americans who lack insurance, and, as Jim points out, Medicare, insurance companies and others have beeen rationing care for years.
If it weren't rationed, Medicare, Medicaid or private insurance would pay for any "treatment" any scammer could dream up, including the laying on of hands, the mumbling of phony incantations, or anything else some Elmer Gantry could think of. My advice is to pay attention to what Jim has to say, and to follow his blogs on health care.

[johnashman]

It's not about the start of rationing. The worry is about who will do the rationing and just how bad rationing might get with the terrible economy. It's not an unfounded fear. Washington bureaucrats are terrible at this sort of thing. Potentially worse, even far worse than insurance company bureaucrats.

I have a plan that should minimize rationing by maximizing efficiency, but it seems that no one will look at it. So we get stuck with whatever the Democrats come up with, like it or hate it.

[expired]

Thank you for showing your support for a public health insurance
option and reform for America's health care system.

Now, please urge your friends and family to sign the petition as
well by giving them this link or forwarding them the message
below:

http://ga3.org/campaign/healthpetition?source=hc_ty

Thank you for supporting this important effort.

Sincerely,

Dick Durbin
Patrick Leahy
Chuck Schumer

[madeoutofmud]

Jim,

50 million uninsured drive up the cost, becasue those uninsured do get care. EMTALA (emergency medical treatment and active labor act), was enacted to guarantee that hospitals treat people who come to the ER. Those costs are passed along to "paying customers." To compensate, commercial insurance is billed more, and that cost is passed along to employers who purchase care. Because of the rising cost of insurance, employers pass on cost in the form of higher co-pays, etc. Also, having a large uninsured population costs us all in intangible ways. It makes people poorer, which drives up the cost of social services. It puts us at risk for epidemics of infections. California voters passed prop 187 in 1994 to deny health care to illegal immigrants. Aside from the morality of doing that, the stupidity of doing that is amazing. Do we want to deny health care to anyone who might have an infectious disease such as tuberculosis?

The to deal with cost is making the risk pool as big as possible, meaning single payer. Yes, there will be rationing, like there is NOW. Hopefully rationing will be more rational - paying for what works, and not paying for what doesn't. Not just rationing care becasue some are wealthy and get too much care (which is as dangerous as getting too little), and some are poor and can only get care when they are so sick they need an ER.

[Jim Jaffe - Huffpost Blogger]

Made,
Thanks for your thoughtful comments, which are certainly not illogical. That said, I'd appreciate any documentation you can provide for the argument you make. If I understand you, you're saying that emergency room charges at hospitals that do a lot of uncompensated care are higher than those at hospitals that don't. I've yet to see evidence that this is true. I do know that the insured pay less than the uninsured who have money because hospitals significantly discount the "rack rate" to insurers. So it is probably true that the rich uninsured are subsidizing the poor uninsured, but I'm not sure we have data to push us beyond that. would love to see any numbers you care to share.

[madeoutofmud]

All hospitals provide some uninsured care . With 50 million uninsured, they are everywhere, in every city. It's not that ER charges at hospitals that provides more uncompensated care is higher than ER charges at a hospital that provides less. It's that ER care is more expensive than clinic care . It's more expensive to run an ER than a clinic. Uninsured patients often don't have the option to go to a clinic for ongoing care, so they use the ER. I work at a hospital that has seen charity care rise from about $9 million in 2004 to $60 million last year. For a hospital (or any business) to remain solvent, that needs to be made up. The costs billed to insurance rises, and thost costs are passed on to the employers who purchase insurance. And because health care costs are crippling companies, they are passing more of those costs onto us.

The rack rate is irrelevant. Hospital costs are so high that most care for uninsured people ends up as non-collectible debt. In fact many insured people can't pay their portion - the deductibles or the co-insurance. that's the 20% that insurance doesn't pay. medical costs are expensive, and 20% of a big number is still a big number. In a crappy economy those bills often don't get paid. The uninsured with lots of money is a mythical beast. Most uninsured are people we see daily who work at small businesses that can't afford to pay for insurance.

[madeoutofmud]

The word limit is making it difficult to make my argument more complete. The basic issue is that uninsured patients don't get completely excluded from health care. They get health care in the most expensive setting, often at a later, more expensive stage of disease. By law ER's have to care for these patients, and if they are sick enough to have to be admitted they do. Much of the cost of that care is uncompensated, and the hospital shifts that cost to commercial insurers, who pass the cost on to employers. If they employers can't comfortably soak up the inflation in health insurance, the costs are passed on to us, or they just stop offering insurance. In either case the insurance company doesn't suffer, becasue they pass the costs on.

[jsgaetano]

Health care is currently rationed- if you don't have insurance, you dont get health care.

Also, doctors have been rationing healthcare forever- it's called triage.

[CarbonCreditSeller]

If you don't have insurance, you get health care in the US. Go to any inner-city emergency room and you'll see around 80%+ of the people getting treated without insurance. People from Mexico regularly travel to the US to get health care for free from various private hospitals.

[jsgaetano]

Yes, they have it so easy, having to wait 10 hours in a hospital for "free" health care.

Meanwhile... we have US citizens who likewise are dependent on programs intended to help people in the third world. That's how "great" our system is.

[weslenforever]

I'd REALLY like to see some PROOF of that. How many emergency rooms have you visited? And did you talk to every patient and ASK if they've go insurance?
It might be nice to get some FACTS before repeating the RepugnantCan't Party LIES!

[LeftRight]

Okay, I'm gonna go backwards here..

First, you do see some Hispanic people in most ERs. HOWEVER, you are making an illogical jump to claim that people from Mexico are traveling to the US for free care.

Second, yes, you're right, around 80% of the people in the ER have no insurance, and so they are going to the most expensive clinics in the world, the US ERs. Additionally, they are going to them at a later, more expensive stage of whatever disease they've got! That's not the solution!

And third, that's not health care. For a while after I got out of the US Navy, I had no coverage from anyone! The VA wouldn't yet see me, and I had no job providing coverage. I went to my local ER one day when my throat was in so much pain I couldn't swallow ANYTHING. I couldn't eat, I couldn't drink, I could barely breathe. The ER doc saw me for a whole 90 seconds (after a 5 hour wait!!!!) and wrote out a script for an antibiotic and a liquid painkiller. When I went to the pharmacy to get it filled out, and while I could afford the $13 full price of the painkiller, I was most definitely NOT able to afford the $280 full cost of the GENERIC antibiotic!!!!

[johnashman]

Mr Jaffe, you seem more reasonable than most bloggers here, what do you think of this health care plan -

http://64.203.97.61/SolutionsLab/Solution.aspx?Guid=2d50363e-00be-44e8-9251-9a6589ba820d

[Jim Jaffe - Huffpost Blogger]

thanks. I think we'll get a plan that reduces the uninsured population and provides some tools to contain costs. it will be big enough for Obama to claim victory with a straight face, tho not as comprehensive as some of us would prefer. but the legislative process inevitably calls for a half-a-loaf strategy and I can live with that.

[jsgaetano]

Yeah. Big truimph- we vote in Democrats, and still can't get what Democrats want.

[Geekboy]

It's an ethical question which the most people have chosen to ignore. Scientific advances have brought about so many new medicines and treatments which can save lives or improve the quality of life, but we can't afford to pay for them all.
As an extreme example, consider the face transplant surgeries. The doctors who pioneered this have stated that the procedure could "benefit millions of people". No it can't! Who is going to pay for all of those transplants?
Lacking an equitable approach to this issue, we have insurance companies denying coverage on the flimsiest excuses. They do this instead of facing the hard truth that they can't afford to provide the coverage they've promised to their subscribers.
Recently, my wife was hospitalized for four days after fainting at work with a migraine. During those four days, no surgeries took place. They just wanted to monitor her condition and find a medicine to keep her migraines under control. Some tests were done, nothing out of the ordinary. The visit cost $40,000. It was paid for by insurance (after some haggling).
But my point is, where does $40,000 come from?
The medical community needs to face up to this issue and find ways to promote more cost-effective treatment, instead of flashy ones. That's the only way to cut down on the horror stories.

[madeoutofmud]

I'm assuming this article is written tongue firmly in cheek, as in "I'm shocked, shocked to find gambling in Casablanca." It is quite true that health care is rationed - almost 50 million are excluded, driving up the cost to all the rest of us. There are some factual errors and misleading statements in your 6 point list.
1. Medicare's decisions to cover or not cover are generally not as arbitrary as private insurances. Some things are not covered because they haven't ever been proven to work.
2. FDA approves drugs based on trials that show a favorable risk benefit ratio. While the process is imperfect and not free of political bias, it is designed with the goal of patient safety. If their only criteria was the delightfulness of the drug, then cocaine, meth and marijuana would be legal.
3./4. EMTALA is a law that guarantees that anyone showing up at an ER needs to be evaluated and stabilized. It says nothing about acute versus chronic. As for a heart attack hospital option, what are you talking about? Do you know of cases of heart attacks who showed up in an ER and were denied care or denied admission?
5. abortions aren't covered because we've had decades of christianist influence in government .
6.transplants are rationed explicitly. Not everyone is an equally good candidate to survive, let alone thrive after a transplant. And yes, there aren't enough organs to go around, probably because of those pesky motorcycle helmet laws.

[LeftRight]

As far as your 3/4 answers.... If you go to your ER with a cancer related problem, they will stabilize you. What they cannot do is treat the cancer itself, by using chemo and radiation. And as for the heart attack, he wasn't saying that you'd be turned away, he was saying that there is no mandated time requirement for a heart attack victim, so your insurance could possibly say after one day that you cannot stay in the hospital anymore.

[Jim Jaffe - Huffpost Blogger]

can you help me out here? I'm confused about how the fact that 50 million people are excluded (from something -- insurance, care?) drives up costs for the rest of us. Either they're getting the care and not paying for it and the cost of their uncompensated care is apportioned among the rest of us, in which case they are getting the care they need or they're not getting the care, in which case there are no costs for the rest of us to pay. at the moment, it appears that many of us will be asked to pay more so as to provide extra care to those who aren't receiving it, in which case reforms will be driving up our costs -- which is fine with me.

[LeftRight]

They are raising costs for the rest of us because they are getting imperfect care, the cost of which is then apportioned among the rest of us.

[suegar]

All this may be true, but we have a much more pervasive and unfair rationing system in place that you fail to mention. We are rationing access according to wealth and this is confirmed by the correlation between wealth and lifespan in our neo-feudal society.Only those over 65 are afforded somewhat equal access because of our existing nationalized healthcare system for the elderly.

[wlhigh46]

Under the guidelines now being proposed, only "producers" will be reasonably sure of receiving treatment after age 65. I am assuming this means individuals who continue to work and pay taxes. Those who are retired or disabled face real uncertainty as to whether their next illness will be their last.

[Jim Jaffe - Huffpost Blogger]

sounds highly improbable. medicare pays for the post-65 group and will continue to do so.