Thursday, August 13, 2009

Will The ObamaCare Plan Lead to Rationing?

Current public debate over the Obama/Congress health care insurance reform bill(s) has been increasingly fixated on whether or not health care "rationing" would result.

What is medical/healthcare rationing?

"To ration healthcare is to withhold at least some useful medical services from at least some of the people who would benefit from them." (per DrRich at

Does the Obama administration's plan include rationing?

Actually, we already have rationing, but it's not usually recognized.

Medical rationing comes in two flavors, covert and open/explicit.

Covert rationing occurs every day, as doctors and hospitals jump through the hoops required by government and insurances to treat people. The various delays, frequent rule changes, preauthorizations, unexplained denials & etc. are rationing methods covertly practiced on thousands of patients every hour. These techniques are designed to manipulate doctors and patients to change diagnosis and treatment plans for the benefit of the insurance company or government budget. Much of the disgust with insurance companies derives from these practices.

Covert rationing is both ineffective and destructive of the relationship people have with doctors. The additional medicrats required eat up any savings. Doctors become seen as a hurdle between the patient and some desired end. I have had many patients leave my practice angry at me when I have been unable to convince a stonewalling insurance company to pay for something. HMOs are a special type of covert rationing where the doctor performs rationing on behalf of the insurer and for the benefit of him/herself.

Open rationing occurs when an explicit decision is made to not cover a useful medical service ( e.g. no dialysis past age X) and is considered by many Americans to be distasteful, even evil. I practice in a state whose Medicaid system developed a controversial explicit rationing system in order save enough money to cover tens of thousands more people. It worked fairly well until the Federal medicrats put the screws to it. Open rationing is a common bogeyman in American politics.

The Congressional plans have no explicit language establishing open rationing. That means that covert rationing will be the main method of attempting to control costs in the system initially, and it will continue to be both ineffective and destructive. As long as people can make someone else pay for their medical care, no one will be able to quench the unceasing appetite of Americans for all possible care, all the time, immediately, for every ailment and symptom (The Happy Hospitalist often states: FREE= MORE MORE=BANKRUPT).

That is a huge flaw in the Obama plan. It can not control the costs because it cannot control the volume (this is a major problem with Medicare/Medicaid). The volume of services can only be controlled by external controls (rationing) and patient choice ( make 'em pay). Controlling waste and fraud are illusory solutions.

Initial attempts to control costs in a national system will follow the line of least political resistance using feeble and infuriating covert rationing, but in the long run will require explicit rationing as other nations have done. Yes, ObamaCare will have rationing, of the irrational kind.

An excellent source for discussions of these issues is DrRich at, everyone interested in these issues needs to read his explanations and analysis.

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