Many, perhaps most, health policy planners believe that rationing of medical care is necessary and that the best way to ration medical care is to do it “invisibly”. Invisible rationing would not mainly be enforced by making people follow complicated rules, nor by price, nor by obliging people to queue up for treatment – but instead would flow naturally downward from government budget ceilings imposed on physicians and hospitals. The policy wonks usually then add “combined with universal health care access”. Sounds nice, doesn't it?
Well, I think this is more like a hope chest than a plan, and I think the experience of other countries reveals the difficulty in this set of beliefs.
First of all, the record shows that such rationing systems are not more fair or more humane. This blog alone has posted numerous examples of failures of government-run rationing systems to behave in uniform or humane ways, for example – here and here and here and here and here and here and here and here and here and here. There are many, many more examples, including Medicare and Medicaid in the US. The record shows that, among its other problems, explicit rationing results in (1) the use of governmental power to deny care and (2) everyone being treated equally poorly. Surely America can do better.
Can a system with budget ceilings hope to simultaneously offer universal access? I doubt it. I can’t think of a single example in which the access to care; or the quality of such care; or both, are not compromised when government sets the budget. Indeed, the reality of people queuing up for medical care and the linked examples from countries that have such budget controls refute this hope.
(Of course, the politically powerful or “the rich” are always able to escape these outcomes because they can jump the queue or pay extra for better treatment or go abroad for their care. Recall a couple of years ago the prime minister of a Canadian province who chose to visit a U.S. hospital for his treatment. That is but one of many similar examples.)
There are more specific questions people need to be asking themselves. Why would you prefer to give some politician or anonymous bureaucrat the ultimate power over your family’s access to medical care? Why would you want to allow the government to make such decisions for yourself or your family “invisibly”? Why would you accept decisions about your family’s medical care that are made without your knowledge? Or that are forced on your physician without your knowledge? Do you think these conditions would lead to more humane treatment - or would even make you feel more humanely treated? For my part, it all sounds more like a veterinary ethic than a medical ethic. That is, someone called “master” will make the important medical decisions for you and your family, and one day the decision will be to put you down. And these decisions will have the force of law. Seems to me that is highly worrisome, and not the best America can do.
I’m certain no one would feel more humanely treated if private insurance companies made these decisions about one’s family’s medical care invisibly, behind the scenes, unilaterally reducing the amount that will be spent, all without accountability. But then why in the world would you trust a government institution to take on this invisible role and be fairer or more humane? What government institutions have ever justified such trust?