I have always had an aversion to health care rationing. Why? Because shouldn’t I be able to get all the health care that I want, if I can pay for it?
I know this is wrong. Enough people who know much more about health care reform than I have told me that I am wrong. But I was never convinced, until I read through Ezra Klein’s pass at a definition of “rationing”:
My hunch, however, is that the only thing that’s really rationing is the thing your doctor tells you is rationing. If he can’t start you on a fourth drug regimen because the insurance won’t pay for it or the government says no, that’s rationing. If he doesn’t start you on a fourth drug regimen because he doesn’t think it’ll help and the focus now has to be on making you comfortable and trying to get you into a clinical trial, well, that’s just good care.
This is a very helpful distinction for me and, indeed, the way we should be talking about rationing. Rationing will always exist. But, ideally, the doctor has my best interest at heart. He or she will make the decision that is best for me. I can buy that.
Also, I should mention that from a rhetorical perspective this is powerful because the onus is put on the insurance companies and the government, rather than the doctor.
But as a recent convert, I still think there is an issue here. How good are doctors at making that decision? Is the decision to forego the fourth drug regimen as clear cut as Klein makes it out to be?
Perhaps not. As Aaron Caroll, over at The Incidental Economist, argued recently, there are two issues here. One is that often “doctors just don’t have the evidence to make good decisions.” But even when they do…
It’s a lot more complicated than that. Physicians are human beings, and just as susceptible to biases as you are. It’s no easier to change their minds, or their behavior, than anyone else’s.
Aaron Carroll is a physician by the way.
So, it’s not that our doctors are not smart enough. It’s just that they are human. And while our understanding of medicine gets better every year, it is still (understandably so) not perfect. So, when confronted with a scared and sick patient, I imagine deciding between different types of care is often very difficult. And if the doctor has trouble making this decision, how can the insurance company or the government ration care responsibly?
At the end of the day, the point of rationing is to reduce health care costs while maintaining an equitable level of care. I like Klein’s distinction. But, unfortunately, I’m not convinced that the world he describes could ever exist. At least not until we have a much better understanding of the comparative effectiveness of different procedures.