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Abstract literature Rationing Health CareWeek 1
Rationing of Health Care: Inevitable and Desirable – Richard D. Lamm
Introduction
Americans find certain issues in public policy much easier to ignore than to confront. The necessity of
rationing health care is one such issue. Because Americans believe that access to healthcare is a basic
right,1 we, as a society, have avoided facing the hard fact that it is not feasible to provide, on
demand, all needed medical procedures to every individual who could potentially benefit from them.
Unlimited needs, or at least unlimited perceived needs, eventually outstrip limited resources. For this
reason, we have avoided open discussions about rationing; it inevitably would become clear to all
engaged in such a discussion that rationing entails denying individuals some measure of health care
that otherwise would benefit them. Rationing is felt to be unfair, unethical, and potentially
discriminatory. Every health care provider knows that we already ration healthcare. Much has been
written about the thirty-five to thirty-seven million Americans who have no health insurance and the
approximately thirty million others who have inadequate insurance. Upon consideration, we cannot
deny that we already ration by price, geography, and a number of other means. We tell each other,
however, that this is "indirect rationing" and apparently we find it morally easier to accept indirect
rationing than "direct rationing. "A sin of omission is easier to live with than a sin of commission.
1. Better Health Through Rationing
Any solution to our health care problems will entail more than recognizing these realities. A nation
does not maximize its health until it starts to ask the hard question: How do we prioritize our money
to buy the most health for the most people? Buying the most health for the most people should be
the standard. Modern governments historically have attempted to achieve the greatest good for the
greatest number. Public spending on health care should attempt to maximize the nation's health, not
individual health. We should not apologize for rationing; we should promote and advance it. We fail
to explore the "opportunity costs" of limited dollars unless we admit that we cannot pay for
everything and start to ask: "How do we maximize our health dollars?"
In a world of limited resources, we cannot say "yes" unless we say "no." We cannot explore the best
use of our resources, the so-called "opportunity costs" of each dollar, unless we set priorities as to
what we can afford. We must start a community dialogue about how to put our health dollars to
their best use. It is an inevitable dialogue and we ought to make a virtue out of this necessity.
2. Exploring the Rationing Debate
A) What level of care should we use to judge whether we should ration?
The rationing debate has yet to address the level of care to be used as a yardstick in judging denial.
Some authors talk about "appropriate care," others about "necessary care," and still others discuss
"basic health care." Clearly, these are different standards. Should we provide only "medically
necessary" services or, do we ration by denying something that is beneficial, but not absolutely
necessary? Does "appropriate care" mean everything that is both necessary and beneficial? These
are not idle semantic games. The differences between expansive definitions and constricted
definitions could be tens of billions of dollars.
B) Who rations?
There are four possible players who could ration medicine: (1) consumers; (2) health providers; (3)
bureaucrats and managers; and (4) politicians through public policy. All four have some role in
rationing. The principal role, however, should be played by politicians through public policy.
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, 1. Consumers: Consumers of health care can play a role in rationing by creating living wills,
providing advanced directives, or by just staying away from the system. Consumers limit the
amount of health care services that they demand. The consumer purposely limits the amount
of health care and exercises personal autonomy by saying “no”. The consumer also rations
"by deciding not to transform a legitimate need into an actual and effective demand, for
example, a genuinely sick person deciding not to visit the doctor (free choice)."
2. Health Providers: Physicians and other health care professionals are the only members of
society with a broad enough perspective to estimate and compare the quality of life effects
of different medical treatments. However, physicians correctly ask, "Does my participation in
deciding how to allocate limited health care resources trample on my sworn duty to my
patients?" It must be understood that the nature of medicine forces doctors to meet the
demands of competing obligations. A doctor at a patient's bedside must be the patient's
advocate. But that role does not preclude a doctor from fulfilling the duty to help society set
health care priorities.
3. Bureaucrats and managers: In countries with national health care systems, bureaucrats and
managers play a role in rationing. It has been observed: "They are continually involved in
making financial allocations, both independently and in conjunction with politicians, and also
in supervising and guiding a good deal of service rationing."
4. Politicians: While all of the above will play a role in rationing, a major part of the rationing
decision must ultimately be worked out through the political process. Health care is no
longer merely a commodity purchased by individuals. Government already funds
approximately 40% of all health care spending. Government controls so many aspects of
health care that it cannot avoid its role as rationer. When resources are limited relative to
needs, government must allocate those scarce resources. Resources spent on one patient
means fewer resources available for others with medical needs. Government in these
circumstances unavoidably must decide the common good.
C) Forms of Rationing
Societies ration in a number of ways. Once we admit that we must set priorities, we must inevitably
recognize the need to explore the means of rationing scarce resources. There are four basic methods
of rationing: (1) price; (2) quantity; (3) chance; and (4) prioritization.
1. Price Speaks for itself, (high) prices limits access to health services
2. Quantity Everybody does not get everything, but all get access to good basic health care
3. Chance Impractical.
4. Prioritization First-dollar system and last-dollar systems. First-dollar systems are programs
whereby access to basic services is limited by not paying for the initial costs of care (either
because a lack of coverage for basic services of because high deductibles and coinsurance)
even though expensive tertiary care (organ transplantation or renal dialysis) is covered. Last-
dollar rationing, based on universal coverage, access to very high-cost services is impeded
whereas the initial, or first-dollar, costs of basic care are covered. Thus, although access to
primary physician care is open to all, those who are more severely ill and likely to require
expensive therapies are more likely to confront rationing.
These are never easy choices, but most experts would agree that last-dollar rationing utilizes
resources in a way to maximize the public's health.
Experts also classify rationing methods as either formal or informal. Formal rationing is explicit
rationing of the type Oregon has put into effect. Informal rationing is unofficial and usually involves
doctors or bureaucrats exercising their discretion. There appears to be a logical continuum starting at
one pole with rationing by price, a formal method, and ending, at the other pole, with the informal
methods of rationing by limiting quantity, or rationing by delay. Other forms of rationing, such as
restricting eligibility or imposing restrictions on direct access to specialists, fall in between the two
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,poles. Experts note that formal methods of rationing are generally governed by rules and regulations
and are thus much less subject to abuse than informal methods. These rules attempt to ensure that
people with similar needs are treated uniformly.
There are no rules to informal rationing. Professional judgment and factors like delay, geography,
and withholding information often operate to deny services to needy people. How patients actor
appear physically has been shown to determine, to some extent, the services they receive; this type
of rationing is especially vulnerable to abuse. Some consider "rationing via public relations," where
private funds are sought through the media to fund an expensive medical treatment, as another
form of informal rationing.
Conclusion
One of the principal challenges of any society is to adapt to new realities; it is a painful process
because it often overturns institutions and entrenched values. But public policy is never static; it is
always evolving. Health care in industrial societies has outlived its historic assumptions. We cannot
build a functioning health care system that is based on the premise that we can do everything for
everyone. Infinite medical needs soon exhaust finite resources. Once we recognize that there are
limits to what we can do and spend, we will recognize that a thoughtful allocation of health resources
can actually improve our national health.
Rationing Health Care – A. Weale
The NHS principle is that comprehensive, high quality medical care should be available for all citizens
without financial barriers. But, with the increasing healthcare costs this principle can become an
inconsistent triad. This means a collection of propositions, any two of which are compatible with
each another but which, when viewed together in a threesome, form a contradiction. So medical
care can almost never be comprehensive, high quality and accessible to all at the same time, it can
only be two things.
Now in the USA their solution is high quality comprehensive care, which is not available to everyone.
This isn’t a good solution. A lot of people who need health care are now ignored. Even for the people
with insurance, the costs are too high.
The NHS buys its comprehensiveness and free availability at the cost of quality. The NHS is known for
serving their patients badly, with too few diagnostic tests, not enough screening and an unwillingness
to use expensive treatments.
The third option would be to sacrifice comprehensiveness in order to achieve a core of high quality
care and free available to all. Until now none has succeeded in defining a core range of services that
can be made to work without severe qualifications.
This conflict cannot be solved by just dropping the least credible proposition. Such value conflicts are
the essence of public policy. To suppose that we can escape this conflict of values by retreating to an
ideologically and organisationally simpler world casts a veil of deceit over the choices that must be
made.
‘Rationing’ Health Care – Not al definitions are created equal – P.A. Ubel &
S.D. Goold
Experts do all think the costs of health care have to go down, but there is controversy about rationing
health care. People doubt whether the costs can be reduced by eliminating waste, rather than by
rationing health care. Another point is what ration health care means.
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, Many people think health care rationing, by definition, is unacceptable, raising questions about the
usefulness of debating health care. At the same time, a number of people argue that health care
rationing is either inevitable or justifiable. It’s very important in health care that this term is clear.
Definitions of rationing
There is a broad range of meanings people place on the term. Some state that health care rationing
involves inequitable distribution of resources based on inability to pay. Others define rationing as
‘the equitable distribution of scarce resources,’ as the ‘denial of commodities to those who have the
money to buy them,’ as ‘the deliberate and systematic denial of certain types of services, even when
they are known to be beneficial, because they are deemed too expensive,’ and as ‘any set of
activities that determines who gets needed medical care when resources are insufficient to provide
for all.’
The meanings differ in different ways. First, they differ according to whether something has to be
explicit to qualify as rationing. Second, they differ according to whether a resource must be
absolutely scarce before its distribution qualifies as rationing. Third, they differ according to whether
rationing only involves limits on necessary services, or whether limits on any beneficial services
qualify as health care rationing.
The vertical lines separates medical services that are being limited
explicitly vs those that are being limited nonexplicitly. The line is to the
left of the midpoint to suggest that more services are withheld
nonexplicitly than explicitly. The horizontal line separates absolutely
scarce resources from those that are not absolutely scarce. The
horizontal line is above the midpoint of the diagram to suggest that few
resources are absolutely scarce. At least, there is a circle. Inside the
circle are those health care services believed to be necessary, outside
the circle are those who are believed to be beneficial, but not necessary.
The figure can be used to illustrate the differences among different
definitions. For example, section 1 represents that rationing only
includes the explicit distribution of absolutely scarce and necessary resources.
Not all definitions are created equal
Health care rationing is a morally charged term, suggesting difficult decisions with potentially tragic
consequences.
Is health care rationing limited to explicit mechanisms?
Some people define rationing as the explicit denial of health care services to people who could
benefit from them. Here, rationing is about explicit decisions about how many and what type of
health care people will get. This part of rationing is pretty clear to everyone. The question is whether
this is all that rationing involves or if the definition should be extended.
According to the explicit definition of rationing, limiting the availability of health care services by
ability to pay is not an example of rationing. It shouldn’t be limited to only such explicit mechanisms.
Some health care services are really important and limiting them by ability to pay can result in an
type of deprivation and hardship commonly associated with rationing. While explicit mechanisms to
distribute health care resources are examples of health care rationing, they are not the only things
that qualify as health care rationing. Implicit mechanisms are also examples.
Does health care rationing occur only when resources are absolutely scarce?
Some people limit the meaning of rationing only to the distribution of scarce resources. Evans
describes it as “the process by which criteria are applied to selectively discriminate among patients
who are eligible for resources that had been previously allocated to various programs.
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