Who gets health care?: A new book by historian Beatrix Hoffman shows that health care has been rationed in the U.S. for decades.
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Editor's Note: Excerpted from Health Care for Some: Rights and Rationing in the United States since 1930, by Beatrix Hoffman, by arrangement with the University of Chicago Press. Copyright © Beatrix Hoffman, 2012.
During the national debate over health care in September 2009, former U.S. vice presidential candidate Sarah Palin claimed that reforms proposed by the Obama administration would bring "rationing" into the American medical system. Democratic proposals would "empower unelected bureaucrats to make decisions affecting life or death health-care matters," Palin warned. Just a few days later, Harvard Medical School researchers released a study concluding that 45,000 Americans die every year because they lack health insurance and access to health care.
Opponents of the 2010 Patient Protection and Affordable Care Act warn that the new health care law will lead to rationing, or limits on medical services. But many observers point out that health care is already rationed in the United States. "We've done it for years," said Dr. Arthur Kellermann, professor of emergency medicine and associate dean for health policy at Emory University School of Medicine. "In this country, we mainly ration on the ability to pay." In fact, because the supply of doctors, hospitals, and treatments is never unlimited, medical care is rationed in every country, whether by the government, the private market, or some combination of the two.
Why then does the idea of rationing seem so, well, un-American?
One reason is that health care rationing in the United States is almost never called by that name. The word "rationing" evokes the difficult days of World War II, when the government controlled the distribution of necessities such as food and gasoline. Wartime rationing was understood as a necessary and shared sacrifice as the country united behind the war effort. But the term has taken on more negative connotations in the decades since. Now, rationing makes Americans think of shortages, waiting lists, and long lines.
However, a classical economist would say that rationing also simply means the distribution of goods and services by price. Countries with universal health systems ration health care via controlled distribution, whether through national budgeting, government setting of prices and provider fees, restrictions on some services, or a combination of methods. The United States health care system rations primarily by price and insurance coverage—and, this book will argue, many other methods as well. Americans have learned to fear European or Canadian types of rationing, but don't see that the United States practices both price rationing and other types of rationing in health care.
Rationing in the United States is not a top-down, centralized policy imposed by the government. In the absence of a universal health program, rationing occurs in both the public and private health care sectors. It is practiced by government agencies, private health insurance companies, hospitals, and providers, in ways both official and unofficial, intended and unintended, visible and invisible. The American way of rationing is a complex, fragmented, and often contradictory blend of policies and practices, unique to the United States.
Rationing by price, or ability to pay, is familiar to most Americans. Often, this way of allocating health care means that poor and low-income people cannot get care at all, but it also means that they might get different kinds of care in a system that treats people differently on the basis of whether and how much they can pay. It also leads to many people going without insurance coverage simply because they can't afford it. But rationing by ability to pay is only one of many ways in which medical services have been distributed or restricted in the United States. Health care has been rationed by race, in the case of the Jim Crow health system and other types of racial discrimination; by region, in the case of the uneven distribution of health facilities and personnel throughout the country; by employment and occupation, in the case of the job-based health insurance system; by address, in the case of residency requirements for various kinds of health care; by type of insurance coverage, in the case of health insurance that limits benefits and choice of doctor and hospital; by parental status, in the case of Medicaid ( childless individuals are often excluded); by age, in the case of Medicare and the State Children's Health Insurance Programs—and the list goes on. These types of health care organization (or disorganization), which allow access and coverage for some groups but deny it to others, or allow access to certain types of care but not others, have rarely been called rationing. But this book argues that they must be defined as such in order to more fully understand the workings of the American health system and productively debate ways to improve it.
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14 Comments
Add CommentThe EPA and the Department of transportation ration too. EPA cost of a live is about $9 million, for Dept. of Transp. about $6 million.
Reply | Report Abuse | Link to thisTrue, of course. There are practical limitations involved in health care just as for any other endeavor. The Right brought up Government rationing to capitalize on Government phobias held by many. The Left used denial rather than attempting to explain that rationing is already being done – largely by insurance companies that will continue to thrive under healthcare ‘reform’ being established.
Reply | Report Abuse | Link to thisTrue enough - healthcare in the US is rationed, primarily by ability or willingness to pay. Like anything else, most goes to those who are the most productive in our society. Rationing by the government will be, on the whole, worse than the current system because it will burden the system with additional cost and regulation which will consume resources that could be better used in providing care.
Reply | Report Abuse | Link to thisPlease read the excellent article by Peter Singer on the subject.
Reply | Report Abuse | Link to thishttps://docs.google.com/document/d/1XExjwbab_7tm61IKhWBBwz-5Y_CAGLi_t7O3Sul2StA/edit
Study what hospitals need to do when children are born with untreatable conditions.
Health care mostly "goes to those who are the most productive in our society...." Not quite. Unless you think that someone who inherits several million dollars and lives on the investment is more productive than a cashier at Walmart who works 32 hours a week and has no benefits. It is a common mistake to think that economic rewards follow ability or social worth. A career that you love and that contributes to society is more often than not under-compensated. Think social worker, teacher, personal care assistant, carpenter, etc. I get really tired of people who think that anyone who makes less than $100K must be a slacker. It takes everyone off the hook of needing to provide universal health care, which is what the rest of the civilized world does.
Reply | Report Abuse | Link to thisExcellent comment, thank you. It reminds me of the ethics principles my Mother taught me.
Reply | Report Abuse | Link to thisTHE AUTHOR'S FATAL FLAW
Reply | Report Abuse | Link to thisWhen a pregnant illegal immigrant heroin addict from a car accident can stumble into an ER and charge up $250,000 to U.S. taxpayers -- that is not a "right."
It is insane for everyone involved. No sane country would tolerate that kind of rampant idiocy, except the USA.
So, Ivory Tower & NYTimes: please attempt to grip reality. Thank you.
I think your scenario involves too many other social failings on the part of U.S. Immigration, primary health care and assuming that an individual has complete authority to "charge" anything in an emergency department.
Reply | Report Abuse | Link to thisDrug addiction (especially in pregnant women) is a growing concern even among U.S. CITIZENS.
A lax grip of reality indeed.
T, why, of course, it is much more 'noble' with illegal immigrants are involved.
Reply | Report Abuse | Link to thisNot. Just ask the legal American trades-people who lost their jobs to illegal immigrants.
Thanks for making my point, on the fatal flaw of the author. Every little bit helps.
there is a difference when health care is rationed with the involvement of those to whom it is rationed to versus via the very blunt hand of government. Having worked in the public health setting the I can tell you that main force behind rationing is how politically connected the patient is. There is no rationing for those deemed important by the bureaucracy versus those who are not (that would be you and me). If you doubt this I reference you to two articles:
Reply | Report Abuse | Link to thishttp://www.dailymail.co.uk/news/article-2161869/Top-doctors-chilling-claim-The-NHS-kills-130-000-elderly-patients-year.html
http://www.dailymail.co.uk/health/article-2161489/Nine-10-NHS-Trusts-rationing-operations.html
Be sure to read the comments on these stories the detail how people are really treated by the british NHS.
I agree and I can attest to even worse!
Reply | Report Abuse | Link to thisI used to work for a large EMS Service in Tucson, AZ. The company was paid b the Government to transfer Mexican Nationals from Nogales, AZ to Tucson for medical care that they could not get in Mexico.
We would transport the patients into Tuscon and the people woud get their medical care. And, if they did not have transportation back, we would transport them back to Nogales when they were discharged.
All of this was at no cost to the patient or their family. Yet, we had local citizens of all races and backgrounds that could not get medical care because they could not pay.
It is a shame that you don't understand American economics. The productive are the people that produce. Typically, with the exception of row crop agriculture, these are the the lowest paid at any given company. There are the occasional rare exception. Over all, the most valuable in society get paid very little or not at all.
Reply | Report Abuse | Link to thisI'm not poor although I was for a decade or so. Now I'm firmly middle class. My opinion that healthcare is a right is based on the wisdom of the 1800s Kaiser Friedrich Wilhelm of Prussia. Before he died of cancer and his son became the worst (and last) Kaiser in history, he established government health care for all workers. This was a man who was among the richest in the world so this has nothing to do with social status or income. It is all about basic human decency, which you, soccerdad, seem to lack.
Just be honest and admit that you are very self centered and don't really care about others. I much prefer an honest sociopath to a dishonest saint.
This goes back to the post by tsurman7 - there are numerous other failings occurring long before universal healthcare comes into play.
Reply | Report Abuse | Link to thisFirst of all, it is far too hard for a legitimate immigrant to become a tax paying citizen and we have absolute limits on how many can enter. In addition, the wealthy that ruthlessly exploit the illegals don't face the massive fines, decades of incarceration and loss of citizenship they should. If no one will hire them they won't come.
Second, we are doing a terrible job of preparing our children for the modern economy. I'm not talking about the middle class and rich. I'm talking about the millions of low income children who, with proper education and emotional support could become major contributors to our economy. Instead we shoot down their dreams, tell them to have athletes and entertainers as role models even though those people don't do anything useful and then warehouse them until they die, drift into organized crime or go onto welfare.
We have several million USA workers that can't find jobs because the greedy outsourced the work to slave labor countries. I have no problem with building the economies of other countries as long as it doesn't hurt us at the same time. If we required outsourcing to pay the same wage and benefits to the foreign workers that American workers would get then I'd have little problem with it. The more money other countries have the more they buy from us. Works for me but don't screw my neighbor over to pad your pockets and expect me to respect you.
In total taxes the Germans pay about what Americans do but they get a longer lifespan and universal heath care. Why is anyone contented with the USA being second rate?
However, if you read the first link, it talks about and extra 14 months a certain patient gets, he is an a wheelchair and has all kinds of trouble, health-wise. I would not want to live those 14 months under those circumstances, my wife knows that and a living will spells it out.
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