The R Word

So that brings us to the dreaded “R” word. If those other countries aren’t making people pay out of pocket, and everybody has good comprehensive insurance, then why are they spending less? Oh no, they must be rationing health care! Death panels! Nazi euthanasia! Put grandma on an ice floe!

Let’s get a grip. In the first place, we already ration health care. We ration everything. You can only get as much stuff as you have money to pay for or the skill and will to steal. According to one recent calculation there are 45,000 excess deaths in the U.S. every year because people don’t have adequate health insurance. I can’t assess whether that number is accurate but surely the number is not zero.

So Canada and those European countries must be rationing health care some other way. How do they do it? To begin with, here in the U.S., doctors are paid for doing stuff, so we get a lot of procedures and high tech imaging. But a whole lot of it doesn’t do any good at all. Elsewhere reimbursement policy doesn’t favor overutilization, but rather sensible utilization. For example, physicians in the UK are all on salary and hospitals are on an annual budget.

Here’s one example – doctors routinely send middle aged men with no symptoms of heart disease for what are called myocardial perfusion tests, where they inject radioactive die into your veins, have you exercise on a treadmill, and then use the radioactivity to create an image of the blood flow to the heart. However, there is simply no evidence that this has any value whatsoever. It does, however, expose people to radiation. There is no safe level of radiation. There is a risk of cancer associated with this radiation dose, however small it may be for the individual.


So here is the estimable Norton Hadler’s first principle of rationing:

If some medical or surgical act does not advantage me or my family or my patients, it shouldn't be done. I don't care how well it is done, how cheaply it is done, how efficiently it is done; if it doesn't work, don't do it.

Okay, that ought to be easy enough for people to accept. Next I'll get to the hard stuff.