Health care resource prioritization and rationing: why is it so difficult?

Social Research, Spring, 2007 by Dan W. Brock

THE PRIORITIZATION OF HEALTH CARE RESOURCES AND RATIONING IS A paradigm example of difficult choices, and yet one might well wonder why. Individuals are continually forced every day to prioritize their own resources, deciding what to use them for and what to forego. The process could not be more familiar. Since our wants typically outrun our resources, and although we may regret what must be foregone, we learn to make the choices and move on to the next ones. So why is the very idea of prioritizing and rationing health care resources so troubling and controversial?

Americans are deeply ambivalent and inconsistent about health care rationing. On the one hand many like to pretend that it does not take place, but they fear being denied beneficial care, in particular payment by their health insurance plans for care they need. If rationing does not take place, of course, there is little to fear. On the one hand, many say that we are a rich country and have no need to ration health care, but they resist the rising costs of health care, particularly when they result in greater out-of-pocket costs to them. On the one hand, many say that life is precious and money should not enter into decisions about medical treatment, but on the other hand they resist the ever increasing proportion of both our national wealth and their own wealth that goes to health care. And on the one hand many recognize the need to limit the use of some health care, but resist those limits when they are applied to them or others about whom they care.

Now these inconsistencies might simply reflect a perfectly common and understandable desire to have more of a valued good like health care, but not to pay more for it. For goods that we must purchase in a marketplace, we soon learn that this is not a desire that can be satisfied--if we want more, we must be prepared to pay more, and so we must decide how much that more is worth to us in comparison with other uses for our resources. Most Americans, however, do not pay out of pocket the full costs of the health care they receive, but instead have most or all of the costs of their health care paid through health insurance. So unlike goods fully purchased and paid for in the marketplace, we do not bear the full, often most, or sometimes even any, of the real costs of the health care we consume. In the extreme, if we can get it for free, it is hardly surprising that we do not support rationing which will have the effect of denying some health care to us.

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefited by that good will not receive it. This allocation or rationing can take place by many means. The use of a market to distribute a good is one common way to ration it, since attaching a price to a good or service is one way of allocating it in conditions of scarcity and results in some who would want it and could be benefited by it not getting it. One reflection of our ambivalence toward health care rationing is seen in our resistance to having it distributed in a market like most other goods: most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity to be distributed by markets. Despite this widespread perception, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it.

Rationing largely remains a topic that the public, its elected leaders, and many health care professionals prefer to avoid. The avoidance takes many forms. As already noted, a prominent one is to deny that significant rationing takes place. Perhaps we must ration health care resources that are physically scarce such as organs for transplantation, but rationing because of costs is less visible to the insured. Another strategy of avoidance is to employ a restrictive understanding of rationing that characterizes practices that are plausibly understood as rationing as not in fact rationing. When this denial becomes increasingly difficult to maintain in the face of the realities of the health care system, a typical alternative strategy then is to condemn rationing as unjust or unethical and to deny that it should take place. This fits the strongly negative connotation that rationing has with the public and with many health care professionals. If people widely believe that health care rationing does not take place, and that if it did it would be wrong, it is hardly surprising that we have not had a responsible public debate about when and how it should be done. But both of these beliefs--that health care rationing does not take place, and that if it did it would be wrong--are mistaken.

WHAT IS RATIONING?

One source of confusion about rationing is widespread misunderstanding about what it is, or at least widespread differences in people's understanding of what it is. As already noted, I understand health care rationing to be: the allocation of health care resources in the face of limited availability, which necessarily means that beneficial interventions are withheld from some individuals. Rationing can be understood narrowly or broadly, and this account is deliberately broad in order to capture the full range of cases where scarcity of resources, either economic (for example, money) or physical (organs, professionals' time, for example), results in patients not receiving some beneficial care. If we understand rationing too narrowly we will miss some cases that raise people's concern about rationing, which is that they will be denied some beneficial care.