Rationing? What Rationing?

When discussion comes up of government support for universal access to health care, sooner or later an opponent will say, “That will lead to rationing of health care.” Well, there were two stories today on NPR’s “Morning Edition” that clearly demonstrate that rationing is happening right now.

The first story is about drug shortages. Although I’ve written before about “orphan drugs,” drugs that aren’t profitable for pharmaceutical companies because there are too few patients who need them (although they need them critically) to make a profit, these shortages aren’t of those drugs. They’re about labetalol, a well established drug for controlling blood pressure; and the form of calcium that’s used in IV parenteral nutrition; and a well established drug for ovarian cancer. The difficulties have to do with how few manufacturers there are for many of these drugs. But whatever the cause, the result is the same: decisions have to be made about which patients get the drugs and which don’t. In some cases – perhaps in most cases – there may be a substitute to offer. Often, however, the substitute isn’t as effective, or isn’t as cheap; and sometimes there isn’t a substitute to offer. One way or another, decisions are made about rationing care.

The second story is about the a case presented to the Supreme Court of the U.S. today, the first day of the new Court season. The state of California lowered reimbursement to physicians under Medicaid. However, Medicaid is jointly funded by the state and the Federal Government, and the law requires that such changes be approved by the Center for Medcare/Medicaid Services. At first, the changes weren’t even submitted; and when they were, they weren’t approved. They were put in place anyway, and so patients and providers, both hospitals and physicians, filed suit.

Now, the legal issue before the Supreme Court today was whether it was legal for the plaintiffs to sue. However, in the meantime the result is rationed health care. Medicaid doesn’t pay for all the costs of care (that’s not just an occasional problem; it’s part of how the reimbursement is set) so as to encourage providers to control costs. However, like any other good, you can only cut so much before you start doing damage. The patients who don’t get care because doctors can’t afford to provide care (and, yes, in many cases won’t afford – because, remember, the reimbursement doesn’t cover the costs) are the damage. Costs are “controlled,” and care is rationed.

Now, I won’t pretend: I know that care will be rationed, almost whatever program we provide. However, we can make the decisions haphazardly; or we can have the politically difficult conversation to set community standards about how we will ration. Or, I suppose, we could decide health care is a right, and make the political decision to provide it, including determining how to adequately fund it. Nah, that will never happen.

So, yes, I understand that rationing will happen. I just get annoyed when folks want to pretend that it isn’t happening right now.