Archive for Thursday, April 8, 1999

HOW DO WE RATION MEDICAL CARE?

April 8, 1999

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— When Congress returns next week, it will face a debate on health care that has started on a partisan note and may well end in frustration. For anything useful to be salvaged, politicians will have to recognize a truth few of them are willing to face.

It is defined succinctly in the headline of an article in the April issue of the monthly magazine of the National Conference of State Legislatures: "Government Does, Indeed, Ration Health Care."

The author is a man known for disgorging uncomfortable truths, former Colorado Gov. Richard Lamm. Speaking of American medicine, Lamm says, "We are inventing the unaffordable and spending the unsustainable. We need to focus limited resources where they will buy the most health for society."

He cites some of the evidence. In this age of medical breakthroughs, health care has overtaken housing as the most expensive item in the family budget -- and health care spending is growing faster than anything else in state and federal budgets as well. The trillion-dollar annual medical bill represents one-seventh of the nation's economy.

And yet, the United States has by far the largest share of uninsured citizens of any advanced nation, with 43 million having no coverage now. Of 29 industrial countries, we rank 21st in infant mortality, 17th in life expectancy for women and 21st for men.

Lamm is far from alone in arguing that the current health care system is unsustainable. Health and Human Services Secretary Donna Shalala says the same thing. So do many other experts.

The question, as Lamm writes, is not if we ration -- but how. So far, we have chosen to ration by leaving one-sixth of our population uninsured and, increasingly, by trying to let medical organizations "manage" the health care of those with insurance. Since the failure of the Clinton administration's bill for universal health insurance in 1994, efforts to expand coverage have been sporadic and the number of uninsured has grown by roughly a million a year.

What is almost as worrisome is the fact that the major health care reforms being considered in Washington ignore the fact that society must make hard choices about what it can afford -- and how those dollars can best be used. Indeed, they threaten to exacerbate the problem by promising that the privileged will be even better protected.

Consider Medicare. Those over 65 are the only large class of Americans with guaranteed health benefits. A bipartisan commission's effort to slow the cost spiral that threatens bankruptcy of that program foundered on insistence by the White House and most congressional Democrats that every existing benefit be guaranteed. President Clinton even endorsed a politically popular move to add prescription drug benefits to the menu. No one, least of all the president, has proposed a way of financing that level of services -- without new cost-sharing measures -- for the growing ranks of senior citizens, whose voting power intimidates politicians of both parties.

Or take the "patient's bill of rights" legislation tabbed as a high priority by the White House and Republican congressional leaders. The basic provision would guarantee every patient in managed care all "medically necessary" treatments, determined by his or her physician or, on appeal, by an independent arbiter.

The legislation is being propelled by a flood of emotional anecdotes about individual patients whose lives were jeopardized -- or even lost -- by the cost-conscious regulations of a managed care company or insurer. The individual stories are so compelling that the social costs are ignored. If every patient is guaranteed every service that could provide even a marginal benefit in someone's judgment, then what will the economic consequences be? The answer, Lamm writes, is that "the dollars we spend on marginal and futile care are no longer available to spend on needed care for someone else in the system or some other equally important social need."

He adds: "The health care system can no more afford to do everything 'beneficial' for every patient than the education system can do everything 'beneficial' for every student ... or the police department for every citizen. ... We are funding health care by an unsustainable yardstick."

Writing in this vein sounds cold-hearted. But the real cruelty is ignoring these truths. Until we insist that all Americans of all ages -- including the retired -- contribute to the costs of their health care as far as they are able; until we acknowledge that additional benefits for those with insurance are less vital than providing access to basic care for the uninsured, the political finagling over health care in Washington is likely to do more harm than good.

-- David Broder is a columnist for Washington Post Writers Group.

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