Case to be made for rationing medical care

I spoke recently on the thorny issue of medical futility, a subject particularly agonizing for family and caregivers in pediatric settings. I did so at the invitation of Dr. Tomas Silber, director of the ethics office at Children's National Medical Center in Washington.

The use of interventions deemed medically ineffective squarely confronts us with the most plaguing moral question in health care today: Can we fairly and compassionately allocate limited medical resources?

In health care, the specter of allocation — particularly when benefits are marginal, costs are excessive and others can gain from the same resource — lurks in the background. It is the invisible elephant known as "rationing," setting limits by deciding who gets what and when.

Rationing is irrefutably relevant to health care reform. However, in discussions of reform, rationing appears left out of the equation. Because the "R" word is often perceived as un-American, it can be politically self-destructive.

Yet rationing is a reality. Nationally, Medicaid restrictions on mental health services, eliminations from drug formularies, and reimbursement limits for long-term care reflect a subtle rationing. And excluding some 46 million citizens from health insurance is a morally scandalous testament to rationing based on income. As David Mechanic, health policy scholar at Rutgers, asserts, "the problem of uninsurance is one of the prices we pay for a disorganized system in which medical care is better aligned with ability to pay than with need."

Locally, Gov. David Paterson's plan to cut Medicaid reimbursement to hospitals and nursing homes by 8 percent forces providers into tough trade-offs. For instance, St. Peter's Hospital's intended long-term success via building construction and renovation entails suspending matching contributions to around 1,200 employees' 403(b) retirement packages, abolishing merit pay and reducing operating costs.

We are witnessing health care's perfect storm. A worsening recession prompts more people to delay routine tests. According to the American Hospital Association, in the past three months nearly 40 percent of hospitals nationwide have seen declines in admissions and increases in postponed elective procedures. Moreover, more admitted patients are either uninsured or on Medicaid, further straining emergency rooms. And while unemployment swells the ranks of the uninsured, the insured face rising premiums and such charges as co-pays and deductibles.

While we may tolerate some of this, will we accept rationing that is more overt and determined by rules beforehand?

Oregon tried this in 1994. Despite its flawed attempt at explicit rationing, it extended Medicaid coverage to more than 300,000 Oregonians. Would rationing not violate our sense of national identity, individual rights, freedoms and personal choice?

Yet overt rationing is inevitable, particularly given President-elect Barack Obama's promise to ensure that all Americans are insured, a goal we have a moral imperative to pursue. There is no better way to start than with his strategy to cover our 8 million uninsured children.

Universal coverage, however, comes at a price. We must also contain costs and improve quality of care. All three — coverage, cost, quality — are palpably intertwined.

If we expand coverage while containing costs, how will this affect quality?

We first need to determine essential ingredients of a basic health care package to which all are entitled without exception. We will then need to set limits on other health care services, prioritizing treatments according to ethically justifiable criteria, weighing benefits and burdens in ways that are morally sound, transparent, and the result of public discourse and consensus.

Accomplishing universal coverage will be daunting precisely because it requires rationing. Success will ultimately rest upon two factors. First, can we reach a consensus on what constitutes a reasonable basic package of health care? Second, are we willing to alter our mind-set to think more in terms of the common good rather than self-interest?

If we are ready for universal coverage, are we ready for rationing?

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