Among those of us who've abandoned our search for the health-care fairy, there's a realization that the only way to cap costs is to limit care. An unkind and provocative word to characterize that policy is rationing.
In fact, rationing is already pervasive. The challenge lies in doing it better. In a system where experts agree that three dollars of each ten spent pay for services that do no good, that doesn't seem like an impossibly cruel goal. But squeezing out the waste won't be easy or painless.
Convincing patients to do without services they've become comfortable with and providers to do without the resulting fees that have financed comfortable lifestyles is a daunting task.
Our president tries to artfully move things along by promising that all will get the care that they need, not mentioning that some are already getting much more than that. When reformers hint that better care could actually involve less care, their inability to specify who won't get what when inevitably fans public apprehension.
We have a goal -- providing an optimal amount of care -- but lack a reliable roadmap to get us there. We know that some areas -- like Santa Fe -- spend less that half as much per Medicare patient than others -- like Miami -- do without yielding any improvement in health status.
But we don't know how to bring Santa Fe style medicine to Miami, however much we'd like to.
We know there are similar disparities between elite institutions like the Mayo Clinic in Minnesota and Mt. Sinai Hospital in New York City, but lack a strategy to translate this knowledge into policy.
Politicians writing reform legislation are trying to create an infrastructure that would definitively tell us precisely what works and an atmosphere where providers would gravitate toward this standard, even if it cost them money. This has never been done successfully on a large scale, making it difficult to rank proposals to get us there.
In the meantime, people are getting nervous about the realization that Washington would like to cut care and Washington's faint reassurance that doing what's best might be wiser than doing whatever a physician suggests is a good idea.
I personally have no problem with cutting insurer profits or eliminating needless paperwork, but neither of these satisfying changes would be adequate to fund a program that provides adequate care for all.
Drew Altman of the Kaiser Family Fund outlined the problem when he noted that while experts believe that 30 percent of care delivered today is unneeded, 67 percent of those polled think Americans are being denied the care they need. That tension underlies today's frustration.