Map of life expectancy at birth from Global Education Project.

Tuesday, June 23, 2009

Let's get rational

Norton Hadler -- one of the good guys in the white coat -- on rationing. Back when I was a student at the Heller School, our dean, elder statesman of health economics, always used to say, "What's wrong with rationing? It means, to apportion reasonably." The word is related to rational; it's a good thing.

Now, it obviously has bad connotations because people associate it with scarcity. There isn't enough food to go around so everybody gets 5 pounds of rice and an onion every week, that sort of thing. But too much food is bad for you, and if you have a tendency to overeat, you should ration your portions. Health care is the same way -- more is not better. Too much ice cream will make you fat, but it won't bankrupt you. Too much health care, unfortunately, will not only hurt you and just possibly kill you, it will cost enough to buy 20,000 or half a million banana splits.

What bothers me about the way this whole debate is going is that you have to read fairly obscure columns by people like Dr. Hadler in order to get a decent explanation of the issues. Politicians who favor meaningful reform won't confront the sophistry of conservatives head on, they just try to duck it. "The last thing in the world we want is a government takeover of health care," they'll say. "What we are proposing isn't anything like rationing, we aren't going to take anything away from anybody." Who in the Congress is appearing on Press the Meat to say:

Consumers don't undergo expensive surgery and procedures, or take pills every day for their entire lives, because they aren't paying out of pocket for these things. I'm not going to run over to the hospital and get a triple bypass or a PET scan or have three vertebrae fused just because my insurance will pay for it. The only reason I would ever do any of those things is because my doctor tells me I need to. So, wouldn't you like to be reasonably sure that when your doctor tells you to have surgery, she or he is right?

Wise doctors like Norton Hadler, who truly care about their patients, know that right now, you can't be sure. That's not a rap on the profession -- doctors are human, clinical decisions are very complicated, and there are all sorts of influences on people's decision making of which they are not even conscious. Physicians make their money by doing stuff, and the incontrovertible truth is, they do too much of some stuff. They're going to have to do less of that stuff, and that means the ones who specialize in unnecessary stuff won't make as much money. That's bad news for them, which is why the AMA is trying to prevent it, but it will be good news for the rest of us.

That's the truth. Now will somebody get up on the floor of the Senate and say it?

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