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.
The United States is unique because of the complex, sometimes hidden, and frequently unintended ways it rations care. The United States is also unique among affluent nations because it does not officially recognize a right to health care. Apart from the right to assistance in an emergency room (which has existed only since 1986, and even then only requires that patients be stabilized), Americans have no legal or constitutional right to medical care. Many other nations include a right to health care in their legal or constitutional documents, and virtually all affluent democracies other than the United States provide universal health coverage as a matter of right to their citizens. The scope and definitions of these rights to health care differ, and countries have created many different kinds of health care systems to help enforce them, but what they all have in common is that rights to access and / or coverage are universal, applying to all citizens of the country. The few rights in the US health care system—such as the right to emergency treatment and the rights of senior citizens and veterans to health coverage—apply only to particular groups of the population or to particular types of care. These selective, limited health care rights are another way that coverage and services are rationed in the United States, although we seldom talk about it this way.
Despite the lack of universal health care rights in the United States, the argument that health care should be a right is a powerful one in a country where "inalienable rights" are central to citizenship and national identity. Presidents from Franklin D. Roosevelt to Barack Obama have declared health care to be a right, not just a privilege. Opinion polls for several decades have shown broad public agreement with the statement that access to health care is or should be a right.
This book tells the story of rights and rationing in the development of the American health care system since 1930. Since the United States recognizes few rights in the health care system, while refusing to recognize that rationing takes place at all, this is a challenging task. To uncover the history of rationing, the following chapters focus on the parallel themes of access to health care and the denial of health care. They tell the story of how Americans have sought access to medical services since the 1930s and how the system grew dramatically with the goal of bringing the benefits of modern medicine within reach of everyone. At the same time, the denial of access, and the refusal to make the benefits of health care available equally, have also defined the system. The history of access and denial is the history of the American way of rationing, and of a health care system whose impressive benefits are available to some, but not all.
The clash between the ideal of access for all and the reality of the denial of health care also helps uncover the history of health care rights in the United States. "The reason why there is a fuss over rights to health care is because so many are left out," writes the medical ethicist Larry Churchill.
Excerpted from Excerpted from Health Care for Some: Rights and Rationing in the United States since 1930, by Beatrix Hoffman, with permission from the University of Chicago Press. Copyright © Beatrix Hoffman, 2012.
