July 3, 2009, 7:24 am ‘Rationing’ Health Care: What Does It Mean?

By UWE E. REINHARDT

Uwe E. Reinhardt is an economics professor at Princeton.

As the dreaded R-word — rationing — once again worms its way into our debate on health care reform, it may be helpful to relearn what is taught about rationing in freshman economics.

In their well-known textbook Microeconomics, the Harvard professor Michael L. Katz and the Princeton professor Harvey S. Rosen, for example, put it thusly:

Prices ration scarce resources. If bread were free, a huge quantity of it would be demanded. Because the resources used to produce bread are scarce, the actual amount of bread has to be rationed among its potential users. Not everyone can have all the bread that they could possibly want. The bread must be rationed somehow; the price system accomplishes this in the following way: Everyone who is willing to pay the equilibrium price gets the good, and everyone who does not, does not. [Italics added.]

In short, free markets are not an alternative to rationing. They are just one particular form of rationing. Ever since the Fall from Grace, human beings have had to ration everything not available in unlimited quantities, and market forces do most of the rationing.

Many critics of the current health reform efforts would have us believe that only governments ration things.

When a government insurance program refuses to pay for procedures that the managers of those insurance pools do not consider worth the taxpayer’s money, these critics immediately trot out the R-word. It is the core of their argument against cost-effectiveness analysis and a public health plan for the nonelderly.

On the other hand, these same people believe that when, for similar reasons, a private health insurer refuses to pay for a particular procedure or has a price-tiered formulary for drugs – e.g., asking the insured to pay a 35 percent coinsurance rate on highly expensive biologic specialty drugs that effectively put that drug out of the patient’s reach — the insurer is not rationing health care. Instead, the insurer is merely allowing “consumers” (formerly “patients”) to use their discretion on how to use their own money. The insurers are said to be managing prudently and efficiently, forcing patients to trade off the benefits of health care against their other budget priorities.

These thoughts popped into my head as I sat as a guest in the White House East Room during last week’s ABC News town hall meeting. There a neurologist suggested in his question that the president and his policy-making team seek to impose rationing of health care so that more lower-income Americans can receive it, all the while refusing to countenance that rationing for their own families.

One must wonder where people worried about “rationing” health care have been in the last 20 years. Could they possibly be unaware that the United States health system has rationed health care in spades for many years, on the economist’s definition of rationing, and that President Obama and Congress are now desperately seeking to reduce or eliminate that form of rationing?

Let me remind rationing-phobes what they would find in the huge body of research literature and media reports on our health system, should they ever trouble themselves to read it:

• Many Americans without health insurance or very high deductibles routinely forgo prescribed medicine or follow-up visits with a doctor because they cannot afford it, risking more serious illness later on.
• A 2008 peer-reviewed study by researchers at the Urban Institute found that health spending for uninsured nonelderly Americans is only about 43 percent of health spending for similar, privately insured Americans. Unless one argues that the extra 57 percent received by insured Americans is all waste, these data imply rationing by price and ability to pay.
• A few years ago, The Wall Street Journal featured a series of articles reporting how often uninsured middle-class Americans are charged the highest prices at pharmacies and in hospitals, and how sometimes they are hounded over medical bills to the point of being jailed for failed court appearances.
• Studies have shown that solid middle-class American families — even ostensibly insured families — can lose all of their savings and sometimes their homes over mounting medical bills in the case of severe illness.
• In its report Hidden Cost, Value Lost: The Uninsured in America, the prestigious Institute of Medicine a few years ago estimated that some 18,000 Americans yearly die prematurely for want of the timely health care that health insurance makes possible and that can prevent catastrophic illness.
• A recent study by an M.I.T. professor found that uninsured victims of severe traffic accidents receive 20 percent less health care than equivalent, insured victims and are 37 percent more likely to die from their injuries.

Need I go on?

As I read it, the main thrust of the health care reforms espoused by President Obama and his allies in Congress is first of all to reduce rationing on the basis of price and ability to pay in our health system.

An important allied goal is to seek greater value for the dollar in health care, through comparative effectiveness analysis and payment reform. As I reported in an earlier post on this blog, even the Business Roundtable, once a staunch defender of the American health system, now laments that relative to citizens in other developed countries, Americans receive an estimated 23 percent less value than they should, given our high health care spending.

To suggest that the main goal of the health reform efforts is to cram rationing down the throat of hapless, nonelite Americans reflects either woeful ignorance or of utter cynicism. Take your pick.