“Rationing”
Thinking about the “rationing” question in health care it’s worth trying to get clear. Sometimes there are shortages of something relative to demand—think of a huge oil shock—and the government decides it wants to impose price controls. That, in turn, leads to shortages. So you can attempt to ameliorate the shortages by rationing. Everyone is only allowed to buy so much gas. During World War II, Great Britain had comprehensive rationing for lots of staple food products—you were only allowed so much sugar, so much tea, so much bacon, etc. That’s rationing.
Now consider something else. If you’re a parent in Montgomery County Maryland, you pay taxes to the county and you get to send your kids to very good public schools. But even though the schools are good, they won’t just do anything you want. Your kid can learn Spanish at government expense, but the taxpayers won’t foot the bill for your kid to learn Burmese. But you don’t normally hear anyone say that the presence of a “public option” for elementary and secondary education involves “rationing” of foreign language instruction. If people have the means and want to arrange private lessons for their children of various kinds nobody is stopping them. And certain forms of this sort of supplemental instruction—Hebrew school in synagogues, Sunday school in churches, piano lessons or Kaplan test prep—are quite common.
61 Responses to ““Rationing””
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July 19th, 2009 at 5:30 pm
During World War II, Great Britain had comprehensive rationing for lots of staple food products—you were only allowed so much sugar, so much tea, so much bacon, etc.
Maybe it wasn’t as comprehensive as across the pond, but the USA had rationing for “staple food products” too, didn’t we?
July 19th, 2009 at 5:32 pm
Also, doesn’t Medicare already ration to some degree? Are there absolutely no medical conditions the government won’t pay for?
July 19th, 2009 at 5:35 pm
However, you’re kid’s not likely to die from lack of access to Burmese-language classes. Also, it’s possible that parents of moderate means can actually afford Burmese lessons. The analogy doesn’t seem tremendously useful.
July 19th, 2009 at 5:37 pm
OK, I will buy the Yglesias view of rationing..
July 19th, 2009 at 5:48 pm
If you take away peoples ability to provide private care for themselves through huge tax increases you force them to turn to government services which must be rationed by definition.
July 19th, 2009 at 5:50 pm
You’re no doubt correct Matt, but I think you might be giving the critics here too much credit. Claims there will be “rationing” is just more conflating of any heath care reform with a completely government run heath care system where private heath care provision is barred by law.
Even in the extreme this is of course plenty of reasons to think that “rationing” is a illusory critique if such a system is compared to anything other than Utopian system where everyone gets everything they want, but it at least does make some sense.
July 19th, 2009 at 5:52 pm
Matt, I was hoping you’d link to the excellent piece in the NYT by Peter Singer on rationing.
http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html
(Not that Matt reads his comments.)
July 19th, 2009 at 5:52 pm
Well by that logic the Iraq war was a form of rationing heath care.
July 19th, 2009 at 5:53 pm
If you take away peoples ability to provide private care for themselves through huge tax increases you force them to turn to government services which must be rationed by definition.
Feel free to explain how the tax increases, which start at $350k and really only get big at $1 mil plus, are going to take away anyone’s ability to provide private care for themselves.
And, of course, every service is rationed by definition. But currently they’re rationed by cost instead of by oversight, which means people who can’t afford them simply don’t get them.
July 19th, 2009 at 5:54 pm
James Yglesias is not making an anology he is making a counterexample. He is saying that the principle that government must provide unlimited services is insane and the counter example of foreign language classes proves it. I don’t see why this is a controversal point. The field of economics exists because we can’t satisfy our unlimited desires.
July 19th, 2009 at 6:02 pm
Prices ration. Always have, … well, we’ll see.
July 19th, 2009 at 6:06 pm
Sycophant of the Bourgeois, yes if government provides services to people those services must be rationed. Alternatively you can not have government services and people can try to buy what services they can afford. I think what your saying is that government shouldn’t provide services to poor people because then the government gets to decide how much its going to help them. I think a better criticism of Yglesias view is that if the government is going to help poor people it might be more efficient just to give money to them and then let them decide what they want to do with that money. Yglesias thinks that government can help poor people more by not just giving them money and instead providing services to poor people that the government thinks poor people need.
July 19th, 2009 at 6:06 pm
James Yglesias is not making an anology he is making a counterexample. He is saying that the principle that government must provide unlimited services is insane and the counter example of foreign language classes proves it.
My point was that the life-or-death nature of healthcare makes it fundamentally different than language classes. I don’t consider it meaningful as a counterexample either.
July 19th, 2009 at 6:08 pm
So you think government can provide infinite health care services?
July 19th, 2009 at 6:29 pm
My point was that the life-or-death nature of healthcare makes it fundamentally different than language classes. I don’t consider it meaningful as a counterexample either.
Gee James, of course it’s a good counter example as far as it goes. MY is talking about rationing, debunking – I’d say fairly effectively – the idea that if a government provides something, it’s proscribing access to that thing, as in WW2. ‘Rationing’ is a scare word.
All the arguments against getting a serious start on reforming healthcare are pretty much based on the logic of scare words.
July 19th, 2009 at 6:32 pm
Also, it’s possible that parents of moderate means can actually afford Burmese lessons.
Those same parents could probably afford expensive medical care not covered by their government plan. If I take out an insurance plan that only covers fairly rare procedures – while all my routine medical stuff is covered by the government – how expensive would that insurance be per month? Probably less than Burmese lessons.
July 19th, 2009 at 6:42 pm
“I think a better criticism of Yglesias view is that if the government is going to help poor people it might be more efficient just to give money to them and then let them decide what they want to do with that money. Yglesias thinks that government can help poor people more by not just giving them money and instead providing services to poor people that the government thinks poor people need.”
Thinks? Everyone needs health care, just like everyone needs primary education and protection from crime. When the government provides these things, it’s not just because it thinks it’d be a nice thing for people to have, it’s because the country is better off when people are educated and therefore contributing to the economy at a higher level, when they’re spending money in stores rather than giving it to muggers, and when they’re spending more time working and raising families and less time lying in bed sick or dying.
July 19th, 2009 at 7:03 pm
“Matt, I was hoping you’d link to the excellent piece in the NYT by Peter Singer on rationing.
http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html
(”
What a disgusting person and what a disgusting system the Brits have – asuming it is represented apropiate in that article. Pointing out that the US system is worse and even more disgusting as the article shows does not make the British system any better.
July 19th, 2009 at 7:18 pm
urgs, I don’t get the disgust. Singer is simply laying out some facts: if resources are limited, then we need some principle for distributing them. Why exactly is it disgusting to limit the amount of resources that will be spent on extending a life for a few weeks or months, if those resources can be better spent elsewhere?
July 19th, 2009 at 7:28 pm
Because it’s not your choice to make, capiche?
So can anyone explain to me why rationing under the absolutely workable plan the Democrats are cooking up won’t make the American health care system *absolutely worse* from the putatively improvable status quo? After all, that’s precisely what seems to have happened in MASSACHUSETTS. (Premiums; up. Waiting times; up. Quality; down. Doctors fleeing the system? Of course.)
July 19th, 2009 at 7:36 pm
This is why people in Canada and Brittain routinely keel over on the street while waiting in line for health care.
…wait a minute…
July 19th, 2009 at 7:41 pm
Most current insurance plans have a maximum payout per year and/or per incident. So there is defacto rationing if you need treatment that goes beyond your $200M annual or $1MM lifetime limit.
July 19th, 2009 at 8:09 pm
Sure, “just laying out the facts”. He is obviously endorsing the British system. As a bonus, he also endorses the idear that rich people should be alowed to buy more lifetime and the idear the value of human life should be measured with some vodoo theory about rational decission makeing and some odd ethnics that puts patent rights over human life. The idear to outsource ethnics to the market does not work. Outsourcing to the market is not real outsourcing, but a retarded hidden value judgment in itsself – one that reveals rather low ethnical standards.
July 19th, 2009 at 8:13 pm
That right there is a logical and grammatical mess.
July 19th, 2009 at 8:28 pm
The rich can buy safer cars, homes in safer neighborhoods, more nutritious food, security systems, bodyguards and so on. Your choices are either that money can buy at least some extension of life – or marxism. I believe in a very egalitarian system of healthcare, but there is no more need to eliminate inequities entirely than there is to eliminate all inequities in life.
I certainly hope people making medical decisions think rationally about the value of the lives they are affecting. If a liver available for transplant can go to an alcoholic or an otherwise similar non-alcoholic, I hope they make the rational choice.
People who refuse to put value on life kill with ignorance.
July 19th, 2009 at 8:31 pm
Think of it like a written version of pointillsm.
July 19th, 2009 at 8:40 pm
Just what is wrong with rationing? It may not be the most pleasant or popular way to distribute a good but it’s certainly _fairer_ than having it distributed according to how rich you are.
July 19th, 2009 at 8:46 pm
what a disgusting system the Brits have – asuming it is represented apropiate in that article.
Yes, because having an independent body evaluate, on an ongoing basis, when it’s appropriate to authorize expensive and/or experimental treatments, is clearly more “disgusting” than having those decisions made by one’s bank balance or the whims and shareholder-dictated profit margins of a health insurer.
And while spelling flames are usually tedious, you’re making Matt look good here, and that’s not a great basis for trusting your judgement on the piece. (I don’t agree with Singer’s overall thesis, but the NICE model, for all of its tabloid-rage inspiring decisions, seems less ethically problematic than the US model of throwing money at end-of-life treatment.)
July 19th, 2009 at 8:56 pm
“rationing!” is a yet another bullshit canard from people who are irrationally afraid of letting the government do anything but kill brown people. fuck them.
July 19th, 2009 at 9:08 pm
So given that the Massachusetts system is worse than the status quo, but most European systems are better than the status quo, which aspects of European systems should we adopt?
July 19th, 2009 at 9:27 pm
tomemos perhaps Yglesias is right to think that government should provide health care services to the poor itself rather than simply giving them money so they can do so themselves. The nature of things is that there are certain implicit gaurentees that a representative government must provide to its citizens. For instance if a man was to spend all their earnings on alcohol and booze the government might not be able to stand by and let him starve for his sins. Given these gaurentees it seems reasonable for government to step in at a different point substituting its judgement for his. But it is difficult I think to know clearly when people will stumble and when they will not and I think government should exercise some due caution before it dictates to people how they should live their lives. If you just gave money directly to poor people they would probably not save enough to cover their medical needs and they would probably not get the preventative care they need and they would probably not even be good at distinguishing a decent doctor from a quack. So I find myself generally in agreement with Yglesias in the proper role of government in this matter. But I think there are rational and sensible arguments against it that do not depend on ignoring the most elementary principles of economics and logic. That government cannot provide infinite health care to its citizens should not be a matter of great debate, nor should it be considered sensible to complain that government will decide how much health care it wants to provide to people. It cannot do otherwise.
July 19th, 2009 at 9:36 pm
Re: If you take away peoples ability to provide private care for themselves
???
No one is talking about doing this. The only reforms on the table would allow people to obtain insurance on their own, not through the government, and pay out of pocket if they preferred. You people are reduced to telling bare-faced lies. Unless you’re so brain-washed that you actually believe this crap.
July 19th, 2009 at 9:36 pm
[...] yeah, read the whole article, it’s good, etc. Here’s an additional point from Matt Yglesias after the jump: Now consider something else. If you’re a parent in Montgomery County Maryland, [...]
July 19th, 2009 at 9:39 pm
President Obama, and Orszag, along with Krugman, DeLong, MattY, Benen, Ezra and all the other mouthpieces are apoplectically pushing this pig by August because they know, like a used car salesman, that you have to close the deal before the suckers get wise to what’s been shoved down their throats (or elsewhere anatomically) and what it will cost for the pleasure.
July 19th, 2009 at 9:46 pm
Or, ho9. they know that the longer the GOP and the Blue Cross Dems are given to spread misinformation and suck corporate cock, the less likely we are to see any reform, as opposed to the diluted reform that invariably comes out of the Senate with its disproportionate number of shitbags.
July 19th, 2009 at 9:46 pm
Where “pig” is code for “decades of Democratic dominance”.
July 19th, 2009 at 10:20 pm
The only people who have aproblem with rationing are the ones who think that the US has unlimited health care at the moment. It shouldn’t be a debate about rationing, it should be a debate about what we ration and who decides.
July 19th, 2009 at 11:10 pm
yet another bullshit canard. the GOP has nothing but lies to offer. they don’t want an honest conversation, they want to lie. fuck them.
July 19th, 2009 at 11:33 pm
**Where “pig” is code for “decades of Democratic dominance”.**
Actually it’s code for default of the US Long Bond.
July 19th, 2009 at 11:37 pm
Right. When did conservatives become hysterical little girls? If we’re not going to be killed by terrorists, we’re going to default, or have inflation, or be eaten by Moon moths, or something.
July 20th, 2009 at 1:06 am
Agreed on the topic of rationing. Health care is a scarce good. There are only so many man-hours of medical care. It is going to be rationed somehow – by the government, by insurance companies or by the amount of green paper in your pocket. The health care debate is a moral issue. Some think it is immoral to ration health care by money, some think it immoral to ration it by anything but.
The debate that I haven’t heard much about is whether there is more social good in curing illnesses which we currently know how to vs. expanding the set of illnesses which we can cure. It seems as though the US has decided on the latter while much of the rest of the world has preferred the former. For instance, assume the US could issue a fiat requring that pharmaceuticals be effectively given away for nothing. That would do an excellent job of addressing the “broadening coverage” issue at a serious cost to future capabilities. What is the point of “ok, now that the collective ‘we’ can cure all these diseases, let’s actually see them implemented”
July 20th, 2009 at 2:45 am
I think what Matt is saying is the rich can have whatever the fuck they want. If the top 10% wants to chew up 40% of the available health care resources spending out of pocket -fine. Go ahead. The rest of us 90% will divvy up what’s left of health care resources and be thrilled to do so. Just let us.
I mean, it would be a better deal for us hoi polloi than say, the Wall Street giveaway. Bankers got 3 trillion in cash, the American people get 16 soon to be 20% unemployment. Or, the arrangement we have with the Military-Industrial-Complex, which gets $1 trillion every year while nation saving renewable energy R&D gets $8 billion. And who in our lowly ranks can forget, without bitterness, that the richest Americans have received $1.5 trillion in kickbacks from the Bush tax cuts while the Average Joe gets to pathetically dream of one day being able to experience a very short bullet train ride -hopefully by or around the year 2063.
July 20th, 2009 at 7:27 am
Re: The only people who have aproblem with rationing are the ones who think that the US has unlimited health care at the moment. It shouldn’t be a debate about rationing, it should be a debate about what we ration and who decides.
Precisely. Rationing by wealth (i.e. thru market mechanisms) is a form of rationing too.
July 20th, 2009 at 7:30 am
Does Best Buy ration flat screen TV’s. If you can’t pay you don’t walk out with one. Health care in the US operates on the market system right? So your baby has a 104 temperature and you go to the Emergency room. If you can’t pay……….
Well this extreme point shows that we, or some, pretend health care is based on the market model. Ultimately this pretense leads to the logical, rhetorical, practical and policy crack up that is health care in the US.
Step one in this debate, or whatever you want to call it, it is vital to make the market model pretenders to admit the market model is a sham.
July 20th, 2009 at 7:44 am
Re: So your baby has a 104 temperature and you go to the Emergency room. If you can’t pay……….
In the interest of accuracy, the ER might treat the baby and reduce the fever, but I believe they would not (assuming she doesn’t have insurance) treat the underlying condition. Someone can correct me on this- this is not my area of expertise.
July 20th, 2009 at 8:29 am
Walt (30) and Benjamin (20), how is it a given that the MA system is worse? The highest rate of insurance in the US, lowest spending on the free care pool & health safety net and premium growth that matches or is lower than most of the country.
To just take “(Premiums; up. Waiting times; up. Quality; down. Doctors fleeing the system? Of course.)” from Benjamin as a given and move on makes no sense.
July 20th, 2009 at 8:36 am
Njorl wins the thread with “a written version of pointillism”. We’ve all wondered how we manage to understand what we read here, now we know.
July 20th, 2009 at 8:45 am
None of the opposition’s points are substantive. They’re all just distraction, venality, and corruption.
July 20th, 2009 at 9:05 am
Premiums up: MA subsidizes the purchase of private insurance. That raises the price. The Dem plan creates a public insurer without a profit motive. That keeps premiums down, plus the bargaining power of a single, large insurance group keeps the cost of the actual healthcare down, in turn, holding down not just the premiums of the public plan, but also those of private plans.
Waiting times up: Obviously, with more people suddenly able to seek health care treatment, and no sudden increase in capacity to treat them, there will be a short period of increased waiting times.
Doctors fleeing the system: Moving practice from Massachussets to Connecticut or New York is easy. Where are American doctors going to go? The rest of the developed world will still have more progressive healthcare systems than the US.
These policies will not deter entry into the profession significantly, either. The number of doctors is artificially controlled by policies concerning residencies, not market forces or scarcity of competent individuals. Until earlier in this decade, we were operating under the assumption that there would be a doctor glut, and took measures to counter it.
July 20th, 2009 at 10:22 am
Beatnik policy analysis.
July 20th, 2009 at 10:48 am
Rapier,
As for the baby with the 104 degree temp, I am pretty sure that in most places, the hospital will take care of the kid. I know at least two uninsured people who have staggered into emergency rooms and had major surgeries completed, free of charge. I was a reporter in Maryland for a while, and I believe it was illegal for the hospitals to turn away uninsured people.
As for rationing, Jacob Weisberg added this to the discussion today in Slate:
“All advanced, wealthy countries have structures that are more egalitarian and cost-effective than ours. Each also has its quirks, which tend to reinforce familiar stereotypes. Britain, land of the stiff upper lip, rations care explicitly, providing what to us would seem shockingly minimalist treatment. It doesn’t cover many procedures we regard as standard, such as PSA tests for men in their 50s or even regular physical exams for adults. That’s what you get when you spend 8 percent of your GDP on health care (versus our 16 percent).”
July 20th, 2009 at 11:50 am
Two wrongs dont make it right. So stop excusing the British system with a worse US system. Both are the result of an ideology that lets market fundamentalist economists run every aspect of a country by the way.
July 20th, 2009 at 11:51 am
To have a limit on medical costs is one thing, to have a limit of 30000 pound for a life year is another….
July 20th, 2009 at 12:26 pm
Since the mid-1980’s, there’s been a federal law requiring hospitals to provide emergency serves to anyone who shows up, however once they’re stabilized they can be kicked out. Which means,the hospital will give you the CAT scan and cancer diagnosis for free You’re on your own for the surgery and chemo.
British rationing during World War II was far more drastic than the rationing the US and Canada endured. So much so that when children evacuated to North America returned home at war’s end, they were noticeably healthier and taller than their peers who stayed behind. If anyone is interested in the topic, Maureen Waller wrote an outstanding book about the British home front, London 1945: Life in the Debris of War.
http://www.amazon.com/London-1945-Life-Debris-War/dp/031233804X
July 20th, 2009 at 12:29 pm
re: Doctors fleeing the system: I think they will leave healthcare altogether. There have been several doctors in my area that have left due to rising malpractice insurance. One I know became a real estate agent. Others who have their retirement investments in place will simply retire early. They’re looking at Medicare and Medicaid – which pay barely over or less than their cost for treatments and projecting that onto the future of this healtcare plan. Who would want to deal with the stress of their profession and the long hours if there isn’t corresponding compensation? I think you are severely underestimating the deterrence to people entering med school also.
July 20th, 2009 at 1:13 pm
Rationing has the same route as rational.
Healthcare is not a market. The information gradient between the professional and the patient is too great. This “information impactedness” is so far from the economic idea of markets peopled by buyers with full information and competition as to be ridiculous. If you knew enough to buy healthcare rationally, you would be the doctor!
It’s a tricky argument, because, in a rational system, someone has to be the person to apportion resources: i.e. say you can have this, you can’t. Perhaps it is more bearable just to say rich people can have this, poor people can’t, but the problem is, even from a rightwing perspective, healthcare systems that exlude the poor are not beneficial. Yer Goldman Sachs executive can be as rich as he likes, but he’s one cough away from TB from the indigents in the street if they can’t also access healthcare.
No man is an island and all that.
July 20th, 2009 at 1:19 pm
We already ration in this country. We ration by price. Oil was different in the 70’s because it was rationed through waiting. Time spent in line equaled dollars.
These concepts should not be confused and in the future- we will need to ration based on systems other than price. End of life care, certain types of chronic desease treatment regimes, these are all concepts that will be rationed through comparative effectiveness research. We can’t be afraid of the concept of rationing, we just have to make sure it has the right definition.
Rationing in healthcare doesn’t specifically mean the denial of services or treatments. It means a concerted effort by the medical community (Drs., RN, Health Plans, CMS, facility administrators, home healthcare, etc…) to pursue treatment plans that have been proven and agreed upon to be both more clinically and cost effective than others.
July 20th, 2009 at 1:27 pm
“however once they’re stabilized they can be kicked out.”
Not sure how the federal law works. But in Maryland, they get the surgery. And the after care. And the meds. My roommate had a bowel resection done, plus a month-long hospital stay. Never paid a dime. They never kicked him out.
It’s dangerous to use anecdotes this way. But no more dangerous than pointing out some homeless guy who didn’t get the care he needed.
All I am saying is, there’s an idea floating around that if you don’t have health insurance, you can’t get any care. But that’s simply not the case. I don’t think it’s necessarily great care, and it’s clearly not the best way to build a system. But the idea that there are huge piles of dying people outside of emergency rooms is wrong, I think.
July 20th, 2009 at 1:37 pm
they know, like a used car salesman, that you have to close the deal before the suckers get wise to what’s been shoved down their throats (or elsewhere anatomically) and what it will cost for the pleasure.
This seems to be an unhealthy obsession for conservatives.
July 20th, 2009 at 1:39 pm
There have been several doctors in my area that have left due to rising malpractice insurance. One I know became a real estate agent.
Good. That’s one fewer person who appears to have been in medicine for the wrong reasons. Now to replace that person with someone who wants to be a doctor for the right reasons. That involves addressing the debt burden of medical school — which in turn shapes a compensation hierarchy where a lot of rich dermatologists look down on primary care practitioners.
July 20th, 2009 at 6:23 pm
Re: And the after care. And the meds. My roommate had a bowel resection done, plus a month-long hospital stay. Never paid a dime.
Unless someone agreed to pick up the tab, your roommate almost certainly went broke even if he never paid a dime. Presumably he had tons of unpaid bills and had bill collectors hounding him night and day, with his credit score left in some lower circle of credit hell. At least until he declared bankruptcy. ER care may be legally mandated, but uninsured people will still get billed for (and ruined by) it, and the rest of us pay indirectly what they cannot.