As Congress goes about reforming health care, there is one idea that officials will try not to speak about: bureaucratic rationing. The idea that a bureaucrat could make a decision on what kind of care is allowed and what is not is frightening to the American psyche.
Distrust of government is fundamental to our culture as well as being inherent in our Constitution.
It is interesting how we are able to accept rationing based on "ability to pay" and the free market. Individuals without money can use public resources to some extent but are not able to get the same care as those with insurance. Emergency care will not be denied for lack of funds, but long-range health issues are not well-managed by emergency visits.
Of course, a significant percentage of the public is disturbed by the idea that those without sufficient income must go without substantial care. This is one of the health care problems that President Barack Obama campaigned to change. He wants to provide subsidies for low-income individuals in order to provide them with health insurance.
Insurance companies provide their own version of rationing when they decide what medical care they will cover and what they will not. People are angered when they are denied coverage, but few question the right of the insurers to do so. Insurance companies are businesses and are not expected to squander their resources. Using medical experts to guide them, insurance companies often draw a line at experimental care, care which is deemed “not medically necessary” and care not recognized by U.S. medical authorities, such as alternative care.
Even the prospect of being denied coverage, and this can mean denial of medical care, does not undermine the private insurance system. Insurance is a choice made by contract. Theoretically, at least, you can choose another company, if you don’t like the one you’re with. This may not be true in practice, where insurers exclude pre-existing conditions for individual insurance contracts, though most employer-provided insurance policies have no such exclusions. Nonetheless, these questions are debated as policy matters and will be part of the reform discussion.
President Obama has voiced concerns about the private insurance market as well. He objects to the pre-existing conditions exclusion. He doesn’t challenge the right of insurance companies to manage their resources and set coverage limits but not accept denial of coverage to individuals whose illnesses are otherwise within coverage limits set for others.
The government does have to make some coverage decisions in its Medicare and Medicaid programs. However, it has avoided concerns of rationing care by providing the level of care people are used to in the private insurance marketplace. The Medicare program is generally well-regarded by seniors who participate in it; however, it is projected to have cost overruns that will overwhelm the federal budget if not corrected. This will put pressure on the government to cut back on the care provided. It remains to be if it will be acceptable to ration care out of cost considerations.
Current health care reformers would like to use a public insurance plan or other public medicine model to reform the system. They see cost savings and the possibility of universal coverage. However, the more the government gets into the business of managing medical care, the more it will run into difficulty having to ration care. As opponents of health care reform raise the issue of too much government control, they will be tapping into a strong undercurrent of mistrust that underlies our system.
