September 7, 2009

Rationality and Rationing

Justin Katz

Michael Kinsley has argued that, when it comes to rationing, healthcare reform would only make explicit something that the system does inherently:

In practice, people die all the time because some effective treatment is too expensive. But whenever an issue gets drawn into the political system and becomes explicit, it becomes harder. That is what health-care reform will do to the question of rationing. ...

... The easiest way to raise your averages -- maybe even the best way, if we're being honest -- is to concentrate on the general level of care and not to squander a lot on long-odds cases. But if the long-odds case is you or a family member, you may well feel differently. ...

Here is a handy-dandy way to determine whether the failure to order some exam or treatment constitutes rationing: If the patient were the president, would he get it? If he'd get it and you wouldn't, it's rationing.

To some extent, Kinsley is correct to remind us that the inhumane error is sometimes easier. It's easier to fault chance for outcomes that we failed to avoid. Seeking to address a question that will not go without answer, one way or another, exposes, rather than introduces, our own personal responsibility. But that doesn't mean that we are right to claim responsibility in every situation.

In my view, "rationing" requires a deliberate decision not to provide something with resources under the group's control. Rich folks and presidents will always possess resources beyond a medical system's control, so in that sense, the only way to eliminate "rationing" (by Kinsley's definition) would be to ensure that additional services are not available. An individual's willingness to pay for a particular test, pill, or procedure ultimately sets its worth in the only way that is adequately humane, and because tests, pills, and procedures have absolute costs, wealthy people will have a higher threshold for "must-haves." Poor people's thresholds will often prove to be lower than a moral society should prefer.

It might be possible, in theory, to devise a formula to adjust the equation for individuals such that each expense requires roughly equivalent judgment. In essence, the cost of a procedure would translate into a percentage of personal income and worth: a man worth twenty grand would pay $1,000, while a man worth twenty mil. would pay $1,000,000. The impossibility of making such a system workable should be plain to see. Not only would the wealthy have incentive to opt out of the system, in one way or another, but the society must invest some body with authoritarian redistributive power, making the cure worse than the disease (not the least because the wealthy would inevitably have imbalanced influence).

I wouldn't presume, at this point, to put forward the formulas and guidelines that a fully reformed medical system should follow, but it seems to me that the general principles would not be new. Let people pay for most services as they go, carrying insurance as they choose for life's unpredictables, and let other people form groups and pool money to help as morality requires. There's a bit of trusting in the wind to lift our wings, in such a plan, but I truly believe the outcome would be better when judged by socially holistic criteria.

We simply don't see the ripples of our decisions in the public sphere, but the bigger and faster the man-made vessel that we place in the water, the more extensive, and detrimental, those ripples can be — and the more critical control over the steering becomes.