Why Rationing of Care Won't Work in the US


I recently read an interesting article by Dick Morris called “Death of U.S. Healthcare” posted on The Hill. Morris was a former adviser to Trent Lott and to Bill Clinton. His opinion is that Obama’s health care reform will cause rationing of medical services and he cites several comparisons between the US and Canadian systems. Another article on The Hill cites President Obama’s promise to provide “basic” health care coverage for everyone.

I agree that rationing is going to occur, but there’s at least one thing that will prevent some medical services from being rationed. Let’s use one example.

Suppose you want to cut the costs of health care by no longer paying for costly medical care that does not provide a long-term benefit. You assign your employees to perform a “study” on costly medical care. The study done by your employees (kind of like a study on the effectiveness of a medication that is funded by the drug company making the medication) determines that patients older than 90 years of age on dialysis do not show a significant improvement in quality or duration of life. You then create a new medical practice “guideline” that says, based on this medical effectiveness study, dialysis will no longer be an included medical benefit for patients more than 90 years of age. What happens?

Some families might pay for the bill for future dialysis out of their own pockets.
Some families might just let grandpa die a slow death from his renal failure.
Most families will just call “911” and the red taxi with the spinning light on top will come to pick grandpa up at his home and take him to the emergency department. At that time, grandpa will receive thousands of dollars in lab tests to document that he really is in renal failure and that he needs dialysis. If dialysis is necessary, grandpa will receive emergent hemodialysis thanks to EMTALA. He might even need a day or two in the hospital to make sure that he is “stabilized.” Then the red taxi with the spinning light on top will bring grandpa home where he will sit a few more days … until he needs dialysis again. One little phone call and the whole process starts all over again.

By excluding preventive care that averts an emergency, the government will create a situation in which the same care becomes more expensive. All grandpa’s family has to do is pick up the phone and hit three little numbers and he’ll get dialysis any time of the day or night.

The government will get its wish, though, as it will no longer have to pay for dialyzing nonagenarians. The burden of paying for emergent dialysis will shift from the government to the hospitals. You see, EMTALA requires that hospitals provide stabilizing treatment, but it says nothing about who will pay for the stabilizing treatment. Hospitals will be forced to eat the cost of providing care. As more of the costs are passed on to the hospitals, more and more hospitals will close. Then less medical care, and less emergency medical care will be available for everyone.

EMTALA and the numbers 9-1-1 are two reasons why healthcare rationing inherent with socialized medicine will never be a viable alternative in the United States. Rationing will cause cost-shifting which will in turn cause hospitals to close their doors.


    • Sure. We can station the National Guard at the doors of each and every hospice, to protect staff from the family members who object to their loved ones being essentially forced to die because it’s too expensive to treat them.

      Mandatory hospice is too close to euthanasia to ever be accepted. Particularly as you will always have a protected class (politicians, anyone?) who will still get every available treatment, no matter what the cost.

    • Instead of saying hospice care should be “mandatory,” you can have the same effect by making hospice care is “free” or low-cost.
      Then patients and families choose between paying large amounts of money for futile care or letting relatives die with dignity at little or no cost. See what happens when consumers have some skin in the game?
      The argument that CrankyProf raises is the same one frequently used in England when the socialized system won’t pay for expensive treatments. The government is “letting the people die.” I think that we will see a lot more of these type of sentiments in the future.
      The government that has the power to provide everything to you also has the power to take everything away from you.

      • I agree. I commonly have people demand admissions for their elderly relatives despite a normal workup. When I tell them medicare might not pay and they might be saddled with the cost, they tend to be more amenable to outpatient therapy.

  1. Why can’t our “esteemed” president and his policy wanks listen to this self-evivdent truth, and other words of wisdom for you and others in the health care trenches??? However, in addition to the rationale you post, which I agree with 105%, let us not forget the personal injury attorneys and their special friends and lobbyists in DC. If someone can’t get what THEY want in medical care, or has any sort of adverse outcome, surely there MUST be a lawsuit and free money waiting in the wings! This comes from my background in OB (I’m too much of a wuss for Emergency Nursing) where every drunk G9P5 crack-whore with STD’s and no prenatal care wants to sue the DOCTOR when her child is born small, sick, and permanently damamged.

  2. I totally agree, and there are many other reasons besides this that it won’t work. However, no matter what politician is in office, you can’t change the mentality of the American people. The reality is that Americans in general do not feel that healthcare is worth paying for. When they do pay for it, they don’t want to “see” it come out of their paycheck, like say, they’re mortgage, car payment, or groceries.

    I don’t like the administration’s approach to healthcare at all, but it might just be the complete and utter catastrophe this country needs in order to really see a change in the attitudes of the average American. I do, however, find it awfully sad that lives will likely be lost simply because we refuse to heed caution before it is too late.

  3. If Medicare (or any other government insurance plan) stopped paying for dialysis in certain populations, I suspect that hospitals would feel empowered to refuse that service. Passing the law that specifies rationing is the tricky part.

    • I see the logical conclusion you’re trying to draw, but I don’t think that Medicare follows logic. Unless EMTALA is changed, there will be a distinction drawn between “medical effectiveness” and “stabilizing an emergency”. Medicare may say that the care isn’t medically effective in the long term, but it will still enforce the “stabilizing treatment” required by EMTALA.
      Will the paradigm shift so that patients get a shot of insulin, a few swigs of apple juice, and a kayexelate chaser? That remains to be seen.

  4. I am tired of the short sightedness of the legislators who think that everyone has access to health care, just go to your local ED and that solving a single problem will fix the global problem of health care reform without recognizing that the problem is multifactorial. Unless all the component parts are fixed there will be no solution.
    Americans are too familiar with the concept of the best care at any cost right now, whether or not they can pay. Second, EMS providers need to empowered with respect to who really needs emergent care. The burden should be spread to primary care physicians, specialists etc.
    Now ED’s are holding up the ceiling of the whole health care system. At some time that ceiling will collapse. We already see this in terms of overcrowded ED’s.
    Importanly, unless health care reform includes malpractice reform and EP’s do not have to practice defense medicine and people are not allowed to bring frivolous lawsuits things will not change. Getting out of a frivolous lawsuit may cost thousands or even hundreds of thousand of dollars for a malpractice carrier company multiplied by how many defendents are named. This has to stop before the money is spent. The cost of medical care in this environment is too high and the solution not simple.

  5. How about reforming EMTALA in an effort to eliminate some of its unintended consequences, such as blatant user stupidity, sense of entitlement, etc.?

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  7. I truly hope that as the health care system crashes around us ~ we will have MORE doctors such as Kevorkian ~ who will stand up for an individual’s right to die peacefully. I’m disabled with severe pain, am not terminal, sick of the drugs & side effects, sick of being treated like a “drug seeker”, sick of being bedbound & housebound – and don’t have the gonads to end life myself. I’d be more than happy to save American taxpayers the expense of my disability check and Medicare bills.

    Please remember me – and stand up for Assisted Suicide or Independent Suicide one day.

    Thanks for the blog.

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