Please, Sir, Can I Have Some More?

The most terrifying word at the disposal of those seeking to halt health care reform is “rationing”: it musters deep set fears of having what one has rightfully earned (whether by hard work or inheritance) taken away and divided amongst strangers. Unlike the hyperbolic rants against “socialism,” discussing rationing somehow seems more, shall we say, rational? Having grown up in an Asian immigrant family and now having two parents who vote Republican, I am very familiar with the sentiments and arguments against the “redistribution of wealth.” However, I find it troubling that many people still cling to a status quo that is increasingly less stable and less attractive than imagined.

If health care is not a right, then it is logical that it must be earned. In the present day, health care is acquired through health insurance, an indirect payer, as paying out-of-pocket it financial untenable for the vast majority of Americans (and others around the world). Health insurance is primarily acquired through two means: employment or government sponsorship (for select groups including the elderly, veterans, and certain at risk groups including pregnant women and children). Note that I did not say that health insurance is guaranteed for the poor: acceptance to Medicaid varies from state to state with some being more welcoming than others. Putting aside government sponsorship for a moment, it seems that acquiring employment is a worthy means of acquiring health care privileges: it is key part of the American dream to work hard and reap the benefits of financial and political freedom. However, not all employment offers health insurance benefits. Are some jobs, then, more worthy than others? Is it reasonable that a corporate executive receives insurance benefits but not a checkout clerk at Walmart? Well, maybe seniority and promotions including health benefits are incentives for people to work harder and advance up the socioeconomic ladder. How about this: does it makes sense that a storehouse shelfer at Pepsi receives great health benefits but not the same type of employee at Walmart? (If Pepsi or Walmart are reading this, forgive me if this information is outdated, but these were real-life examples at some point in the recent past.) Is the Pepsi employee’s work more worthy of health care benefits, or was she just smart enough to pick the right company? Progressing down this line of thought, why should anyone bother to be self-employed or work for a small company (your Mom & Pop outfit) that cannot afford to provide employees with health benefits?

The answer to that question is that many Americans are gamblers and risk-takers: they believe they can beat the curve. They won’t be the poor suckers who’ll get diabetes or have a heart attack or a stroke. Unfortunately, this degree of hubris and inattention to detail (e.g. neglect) is precisely what lands patients in front of me in the Emergency Department with their first experience of crushing substernal chest pain or hemiplegia (unilateral weakness). Three intensive care unit days and one regular ward day and tens of thousands of dollars later, they are sent home to recover, only to receive the most unpleasant surprise: the first step toward bankruptcy. (Health care costs are the leading cause of bankruptcy in the U.S.)

Returning to the notion of earning health care, it seems logical that better jobs should lead to better benefits. By that reasoning, doctors ought to have really excellent health care, right? Here is a highly educated class of elite professionals that has one of the highest base salaries among jobs that can be obtained without nepotism or inheritance. The medical profession is still one of the hardest and most competitive professions to enter. Why, then, do we have resident physicians-in-training (in some parts of the country) who have to take their kids to free clinics because their health insurance plans don’t provide adequate coverage for primary care visits? Why does a highly-accomplished clinician in poor health have to choose to work at a seven-day week job in order to maintain health benefits until age 65 (when Medicare kicks in) just to ensure coverage for high-cost medications for a chronic illness?

In reality, health care insurance currently provides inadequate protection against the rising costs of health care. Although health care costs can be reigned in to some degree, new and better treatments will almost always be more expensive (in order to support the research and production). Furthermore, the fear of rationing is irrational for yet another reason: it already exists (throughout the country, but worse in some places than others). I do not mean to improperly generalize the condition of New Orleans to the rest of the country, but the fractured health care landscape provides a glimpse at a future that the current health care systems could lead to without intervention:

• First, New Orleans has a severe shortage of physicians, nurses, and other health care personnel (therapists, social workers, etc.). Many current trends upheld by the current health care system would continue this depletion: the lack of emphasis on primary care, the paucity of protections against frivolous malpractice litigation, and the increasing numbers of uninsured and underinsured patients that pressure physicians into limiting their practices to “concierge” practices (seeing smaller numbers of higher-paying patients, thus limiting medical resources to the whole population).

I heard a quote on NPR this morning from a concerned conservative constituent saying “My friends in Canada tell me ‘Don’t you dare change your health care system to something like ours; it takes me 6 months to get an appointment!’.” Here, in New Orleans, a follow-up appointment with an Internal Medicine/General Medicine physician after a hospitalization at one of the public hospitals (where uninsured patients go) takes 6 months. A follow-up appointment with a Neurologist takes one year.

• Secondly, care for the uninsured in Louisiana follows an antiquated system that could be reemphasized again in other parts of the country if universal coverage is not achieved. Federal funding for Medicaid in Louisiana, instead of being directed toward providing individual patients with health insurance, is funneled into a large “safety net” system that fuels an expensive, inefficient series of public hospitals (a true “two-tiered system” where a majority of white, paying patients go to the private hospitals and a majority of black/Hispanic, uninsured patients go to the public hospitals). As more and more patients become uninsured or underinsured, they will be unable to afford care at more expensive private hospitals. Why is the care more expensive at private hospitals? I’m guessing that the billing departments are better able to recapture expenses via reimbursements and patient payments at private hospitals. If you don’t have enough money, why not just go to the public hospital and tell the hospital administration representative, “I don’t have insurance” and let the federal government pay for your hospital stay and medical care? In other words, private hospitals sometimes have more resources to do a more thorough “wallet biopsy” and have more effective means of discouraging or diverting uninsured patients to public hospitals (when they exist). If your wallet is particularly thick-walled, you can bet that they’ll take the time to sell you out to the collection agency. The same departments at public hospitals are likely more overworked and less likely to obtain reimbursement for the hospital stay from the patient than from the government if the government provides a relatively easy (or consistent) means of reimbursement.

• These changes within the New Orleans health care landscape has led to an extreme polarization of the system. On the one hand, you have public and academic hospitals with a steadily rising patient population due to increasing numbers of uninsured and underinsured patients. Rationing clearly exists here, especially regards to the establishment of outpatient care and specialized care (e.g. psychiatry, specialized surgery, etc.). On the other hand, you have a network of private hospitals that, in order to maintain financial viability and profits, develops a variety of methods to increase volume and expenditures (to be paid by insurance companies) by relying more heavily on expensive diagnostic testing, by calling for more (sometimes of minimal necessity or benefit) consults, by minimizing the duration of hospitalizations for complicated patients (who might otherwise stay for weeks or months at an academic or public hospital which might recoup only a small percentage of the costs), and by scrapping expensive, high-risk, highly specialized departments (e.g. organ transplantation). I recall my experiences with one patient my team followed at a public hospital who waited two months on the general medicine ward for a diagnostic surgical procedure that the stalling surgeon never performed despite a possible plan for aggressive treatment; I saw her two weeks later at a private hospital where she stayed for less than two days, received a “diagnostic” procedure, and was sent home without hope or treatment for her “complicated” condition. Which would you prefer to suffer?

Rationing already exists in the U.S. health care system: it just happens to people who are not picketing the offices of members of Congress. It is a reality that people are dealing with and increasingly greater proportions of our population will be subjected to this reality as more people become uninsured or underinsured. Current proposals for health care reform might not rid the system of the trend toward further rationing, but doing nothing will certainly worsen this problem.

  1. Ben said:

    Great point being made about the existence of rationing — I disagree with single-payer and many of the options laid out by the Obama adminisration, but am oftentimes shocked that people don’t understand that

    (a) rationing already happens
    (b) rationing is necessary to keep costs down

    Of course, mind you, the existence/necessity of rationing doesn’t translate into a good policy prescription about who should be the rationing agent.

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