Sunday, August 9, 2009

Health-Care Rationing - A Practical Construct

The concept of health-care rationing has not been adequately discussed in public because it’s a touchy subject, appropriately so. But a discussion of health-care rationing and treatment delays is imperative as these are serious long-term consequences of government run public and single-payer options. On a recent news program, Secretary Sebelius has indicated that rationing goes on all the time. Yes and no; i.e. not all forms of rationing are equivalent.

First of all, rationing must not be confused with good medicine. A physician’s decision not to order a test or perform a procedure not indicated for a patient’s symptoms or disease is not rationing; rather, it’s just good medicine. We can distinguish three types of health-care rationing: natural, self and fiscal. Natural rationing is a consequence of a limited biologic resource. An example would be limitations in the number of hearts available for heart transplants. Bottom line, not everyone who needs a heart gets one. Self rationing is when a patient’s clinical situation precludes interventional therapies. For example, an individual with a broken hip and advanced cancer of the pancreas with less than two months to live would not receive a hip replacement. Physicians make these decisions all the time. It is most disappointing, to say the least, to hear talking heads and politicians (who, by the way, know little to nothing of medicine) suggest that doctors are not doing this. Furthermore, no one would dispute this form of rationing. Lastly, fiscal rationing is the limiting of health-care because of arbitrary financial constraints; e.g. where an indicated treatment (surgery, chemotherapy etc) that will improve survival and/or quality of life is not provided because of arbitrary measures (generally fiscal, but others such as age would be considered) and/or inherent delays (e.g. insufficient number of physicians). It is this type of rationing that is not standardly practiced in the U.S. and scares Americans.

This article may be downloaded from my website:

Failures of Existing US Government Run Health-Care Programs


1) Medicare beneficiaries do not have the choice of physicians because many physicians elect not to participate in this program, mostly the result of the Medicare bureaucracy.

2) Many Medicare beneficiaries do not seek and/or receive adequate medical care. Medicare does not adequately cover medical expenses and must be supplemented by other insurance. Many Medicare beneficiaries often cannot afford the supplemental insurance. Government regulations will not allow Medicare beneficiaries to pay the difference; the Government’s assumption is that Medicare coverage alone is adequate. [NOTE: there is a television commercial where an elderly individual states that with Medicare AND her insurance she is able to get her motorized wheel chair].

3) The above will be compounded as Congress and the Administration take Medicare funds to offset some of the cost of the government managed public option.

TRICARE (The health-care benefits system for the US military)

TRICARE beneficiaries who have retired from the Armed Services (and their dependents) have even fewer choices in selecting their health-care provider than those in the Medicare system because TRICARE reimbursements to hospitals and health-care providers are less than those of Medicare. Consequently, many TRICARE beneficiaries live near heavily burdened military hospitals and clinics resulting in longer waiting times, effectively reducing access to care. This care is even further reduced for Medicare eligible patients – these folks are put at the bottom of the list for access to military clinics (yes, there is a cap) because they have (or could get) Medicare. A great way to treat our military retirees and their dependents!


VA beneficiaries encounter delays in their access to health-care. Case in point (true story): An elderly gentleman with advanced kidney cancer was given a prescription by his local medical oncologist for a medicine to be taken by mouth for his kidney cancer; the prescription would be filled at the local VA hospital. The VA refused to honor the prescription informing the patient he needed to see a VA medical oncologist. The patient died from his kidney cancer while waiting for his VA appointment; essentially, de facto rationing of healthcare. Nevertheless, you will hear elected officials tout the VA system as ideal.

So, you want another health-care program run by the U.S. government?

This article may be downloaded from my website: