In America, Health Care Rationing is Already Here

Yesterday David Leonhardt of the New York Times wrote about the need for rationing of health care (and all scare resources in general) and Ezra Klein of the Washington Post cited some statistics comparing health care rationing in the United States and Canada or the UK:

A 2001 survey by the policy journal Health Affairs found that 38 percent of Britons and 27 percent of Canadians reported waiting four months or more for elective surgery. Among Americans, that number was only 5 percent. This, Americans will tell you, is the true measure of our system's performance. We have our problems. But at least we don't sit in some European purgatory languishing without our treatments.

There is, however, a flip side to that. The very same survey also looked at cost problems among residents of different countries: 24 percent of Americans reported that they did not get medical care because of cost. Twenty-six percent said they didn't fill a prescription. And 22 percent said they didn't get a test or treatment. In Britain and Canada, only about 6 percent of respondents reported that costs had limited their access to care.

However, it's not just about numbers. These are real people who do not have access to care. Yesterday, in my primary care practice, I saw three patients who had put off necessary care due to costs after losing their insurance.

Ms. F, a working mom with diabetes, cannot afford the premiums for the health plan offered by her employer. Since she has no insurance, she put off coming in for a year, and she had been without medication for most of that time. Last month she was in the hospital for dangerously high blood sugars. This easily could have been avoided if she had better access to primary care and prescription drugs.

Ms. P has severe hypertension and arthritis. She had been without medication for 6 months due to costs, putting her at high risk for a stroke, heart attack, and kidney damage. She's also been putting off a knee operation for years due to intermittent insurance coverage.

Ms. S had a good job until about two months ago. She also had good insurance. We were able to treat her heroin dependence with state of the art medication. It was a great example of how addiction can be successfully managed like any other medical illness. However, she was laid off, she lost her insurance, and predictably she had relapsed with heroin.

Care for the small percentage of individuals with chronic diseases is what is driving up health care costs in America. We should be devising systems to optimally manage these chronic diseases and make it easy for these patients to get care. Rationing health care based on ability to pay is not only unjust, but it also makes no medical or economic sense. If people are afraid that health care reform will bring rationing, they need to look harder into their communities. It's already here.

Aaron Fox, MD