By Philip Caper, M.D.
Bangor Daily News, May 15, 2014
Opponents of universal health care often claim that in order to afford it we will have to ration health care. My response to that old shibboleth is that we already pay more than enough to cover everybody, and that we already ration health care, as we must in a world of finite financial and real resources. The real question is not, “Should we ration health care?” but rather, “What’s the fairest way to do it?”
In all other wealthy countries, where everybody has a right to health care, rationing is done on the basis of medical need. The more urgent the need, the sooner care is provided. Urgent care is provided promptly, and less urgent care may be put off for awhile.
In many cases, delaying care is actually a good thing. There is a growing recognition that in the U.S. some types of care are too accessible, resulting in costly and risky overuse of many tests and treatments that have little or no value, and others that may actually do more harm than good.
In exchange for restricting access to some tests or treatments of little or no value, we could reduce overall health care costs significantly and largely eliminate cost as a factor in deciding who receives medical care and what kind of care they receive. In most other wealthy countries, the ability to pay does not enter into the thinking of either the patient or the doctor.
The U.S. is unique among wealthy countries in using ability to pay as a means of rationing medical care. The results are often devastating. A recent Commonwealth Fund study found that in states where the number of uninsured is highest, rates of deaths from treatable illnesses are also highest. Another recent study in Massachusetts concluded that morbidity and mortality from treatable illness declined significantly after 2006, when health care reform expanded coverage there.
I’m in favor of expanding health care coverage to everybody and rationing through overall budgetary constraints rather than simply pricing some people out of the system. While some with good coverage receive too much medical care, others without coverage receive too little and may wait forever for needed care.
People who face financial barriers to accessing health care often put off beneficial primary care, only to later require care for more serious and expensive illness. Those costs end up being paid by all the rest of us.
Medical tests, procedures and treatments have their benefits, but they also have their downsides. Drugs have side effects, tests and procedures have risks, and all have economic costs. If we agree to limit access to ineffective, marginally effective or downright harmful care, we could more than afford to expand access to everybody.
In many instances, our aggressive, anything-goes style of medicine has caused more harm than good. Mammography and PSA tests for prostate cancer are recent examples. Over 65 medical specialty societies have each recently identified at least five such tests or procedures.
According to a recent study by the Institute of Medicine, we waste over $340 billion a year on unnecessary and inefficiently delivered services. That’s more than enough to extend coverage to everybody.
I believe most Americans would willingly give up something they may want but don’t really, urgently need if it meant a neighbor who needed it more could have it instead. I’ve seen that happen many times here in Maine. But we seem to have a lot of trouble turning our generous neighborly spirit into public policy.
So why don’t we make our means-tested system of rationing more rational, and, like other wealthy countries, base it on medical need rather than financial means? Not only would our health care system become less costly and more efficient as a result, but it would also become more humane.
Such a change would allow doctors to treat patients the way our training and professional ethics encourage and our Hippocratic Oath demands.
And it would make our country yet a better place to live.
Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at firstname.lastname@example.org.