Thinking about rationing

Not long ago I was on the prowl for a comprehensive article on health care rationing, what it means, how it influences policy consideration, and so forth. Well, all I had to do was wait. My Boston University colleague Alan Cohen has published one in the most recent issue of Inquiry. Here are a few passages I highlighted.

On first- and last-dollar rationing:

First-dollar rationing has been the dominant form of rationing in this country, with both public and private payers limiting access to basic services and primary care—either by denying coverage or by imposing high deductibles and coinsurance—even as they pay for more expensive tertiary care, often at the end of life []. In most other industrialized nations, last-dollar rationing has been the norm, with consumption of high-cost services limited via wait lists and constrained supply of costly technology, while universal coverage assures access to basic primary and secondary care. The ACA aims to reduce first-dollar rationing by promoting access to primary care and preventive services. […] First-dollar rationing makes little sense if we want to obtain the highest value for our long-term investment in health care. Instead, first-dollar coverage of primary care andevidence-based preventive services should be the norm, as the ACA strives to attain. Rationing, then, should apply to services that are wasteful or non-beneficial, and in this respect, last-dollar rationing makes more sense because of diminishing marginal returns on expensive tertiary care, especially in endof- life situations.

On access limitations in the context of waste:

Brody (2012), for example, offers two ethical arguments for avoiding waste—that patients should not be deprived of useful medical services so long as money is being wasted on useless interventions, and that useless tests and treatments cause harm through false-positive results and complications. Thus, wasteful, non-beneficial medicine imposes opportunity costs for patients in need and also conflicts with the medical maxim of ‘‘First, do no harm.’’

On entitlement to technological advances and price barriers:

Not only have we fostered a cultural view that ‘‘death should be avoided at all cost,’’ but we seem to have cultivated a growing sense of entitlement to technological advances as they diffuse into medical practice. Finally, because so many Americans still fail to realize that we ration care through price barriers, the powerful anti-rationing rhetoric of today effectively twists an ‘‘inconvenient truth’’ into a convenient lie for political and/or financial gain.

On the need for more than just price barriers:

As Baicker and Chernew (2011) point out, the economics of financing Medicare is complex. Without even a modest tax increase, it will be difficult to finance the program in the long run, and the bitter Congressional clash over Medicare payment cuts to providers seems inherently myopic. Any short-term savings wrung from Medicare or Medicaid with such blunt instruments is likely to come at the expense of both quality and access to care. And no one knows for certain whether the payment and delivery system reforms of the ACA will ultimately be successful. Given these uncertainties, rationing based on factors other than price and ability to pay will be required to curtail future spending. Are we, as a nation, willing to adopt such rationing schemes?

Our blind spot:

We consider ourselves a generous and caring people who are among the first to respond with humanitarian aid in times of global crisis or disaster (e.g., the 2009 Haitian earthquake and the 2011 Japanese tsunami). But we also possess a curious blind spot that makes us neglect our own—be they inhabitants of New Orleans and the Gulf coast following Hurricane Katrina or the millions of uninsured citizens in our midst.

The article is worth a full read. Unfortunately, it is gated. @afrakt

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