Rationing

Rationing involves leaving some people, at least temporarily and against their wishes, without particular forms of healthcare that might benefit them. Some use the label "rationing" only if a person is barred from treatment by an explicit policy or decision. Those operating from this definition often oppose rationing because they believe there are sufficient resources, if managed and distributed correctly, to address at least the most important health needs of all. Others view the unavailability of care as rationing, whether or not explicit policies or decisions are involved. While part of this group also holds that there are sufficient resources to avoid rationing for the most part, the majority see implicit or explicit rationing as unavoidable and tend to favor developing explicit, ethical criteria (Ubel; Blank; Wikler).

A fundamental ambiguity, then, attends the word rationing. Moreover, the word's association with a short-term policy for handling a temporary crisis, such as a shortage of goods in wartime, makes it a misleading word to designate society's long-term task of healthcare provision. So the less ambiguous terminology of macroallocation and microallocation is probably more helpful in most discussions. Nevertheless, the debate over the term rationing has identified two important issues that should be examined before embarking on a more detailed consideration of macroallocation: (1) Does implicit allocation of desired and potentially beneficial healthcare actually occur? (2) Will some form of allocation be necessary in the future?

There is little dispute that implicit allocation of beneficial care does take place. For example, waiting lists for certain types of healthcare have been commonplace in Canada and Europe. There the structure of the system (referral and reimbursement policies, acquisition and location of technologies), rather than the explicit exclusion of people or services from coverage, has limited overall national spending on healthcare (Grogan). In less developed countries, some resources are typically located only in major urban centers and have been unavailable to most of the population (Attfield).

Even in the United States, where per capita spending on healthcare exceeds that of any other country, many have not been able to obtain certain forms of beneficial healthcare. In recent decades, tens of millions annually have gone without any health insurance, and at least as many more have been underinsured—predicaments that have resulted in reduced access to healthcare and in poorer health (U.S. Congress). Employer decisions to limit employee health-benefits packages, as well as governmental decisions to omit services from the Medicaid and Medicare programs, have excluded certain people from potentially beneficial healthcare. So have decisions by health facilities not to operate in the most accessible locations or at the most convenient times, and insurance company decisions to exclude from coverage people with preexisting conditions or other high-risk factors.

Greater controversy surrounds the second question, whether healthcare resources can be allocated so that no one has to go without potentially beneficial healthcare (Kilner, 1990). The possibility of avoiding rationing in this sense of the term hinges on achieving sufficient cost containment. Proposed strategies include reducing expenditures on items less vital to society (e.g., potato chips and advertising); eliminating medical procedures with little health benefit; placing greater emphasis on preventive care that preempts the need for more expensive acute care; reforming tort law to reduce the need to practice defensive medicine; simplifying administration; imposing global budgets on the entire healthcare system; and limiting the large gap between the incomes of physicians and other full-time workers. Various forms of "managed care" arrangements pursue several of these strategies simultaneously by restricting patients to approved providers (e.g., in preferred provider organizations or health maintenance organizations) who agree to limit their charges or forgo fee-for-service entirely in exchange for a salary or per-enrollee payment.

Some commentators contend that significant cost savings could be obtained through each of these strategies. Others disagree, arguing that the scope and cost of potential healthcare benefits are so vast that any savings will prove insufficient to fund needed benefits for everyone. Time will tell how effective various cost containment strategies can be in reducing the need for limiting the access to healthcare. After initial cost savings, however, managed care in the United States apparently has been unable to check the growth of healthcare costs (Ginzberg). Meanwhile, ethical questions have arisen concerning the extent to which physicians can truly pursue patient well-being if they must also serve as "gatekeepers" to conserve society's resources (Willems; S. Daniels). At the same time, the experience of other countries such as the Netherlands, with healthcare systems more nationally coordinated than that of the United States, suggests the pragmatic limits of cost containment (The Netherlands, Government Committee on Choices). Such challenges underscore the importance of making allocation decisions explicit if allocation is not to be shaped by unknown factors and unethical considerations.

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