The R Word

Right now, the big spooky word in health reform and cost control debate is the R word, rationing. Indeed, the Wall Street Journal had an editorial as such.

I have railed against this designation many times. First off, yes the British do have lower cancer survival rates than the rest of Europe. But, even in those countries there is some level of rationing as well. Countries set global budgets. They do make decisions along effectiveness lines to decide how things are reimbursed or not, but perhaps not with the same force as NICE. Overall, the quality and costs of the British system if you measure other matters besides one data point shows it as very high performing. Something that is lost when you look at just these survival rates (and only for certain cancers).

The other problem here is that the U.S. does not really have high quality. We have the worst of all possible worlds. Our outcomes are poor, our quality low, and our costs higher. Again part of this has to do with our obsession with gizmos and drugs rather than preventative care and other matters. We like to have interventions and surgeries instead of wait and see (See my post on Leonhard's article right below).

This post from the New America Foundation's blog, lays out the major problems with the study. Instead of looking at just one quality measure, they look to surveys that measure aggregates (WHO numbers, Commonwealth Foundation). They also look at how our costs are out of control.

Finally, our system does ration things. If you have good insurance, because either you have money or you have some great union negotiated agreement, then you can have whatever you like. On the other hand, should you fall out, you cannot get anything. The rationing is not based on the notions of how much we value things or a willingness to pay. It is almost entirely an ability to pay disjointed from the other. We ration by denying care to those who need it. We do ration. We just would rather not call it that and think we live in a land of oranges and dances.