I have lifted the title for today's blog entry directly from a New York TImes headline (except for the question marks that I have added for emphasis). This interesting article focuses on the health care situation in Richmond, Virginia and links the changes in health care spending over time (particularly Medicare spending) to restrictions on how much capacity is allowed to be added to the system. In general, I agree with the premise that there can be less care given than in the places with the most intense care in the United States without having seriously detrimental effects on health at a population level.
However, I would like to make a few comments on what the article points out. First, a key part of what I describe as the premise of the article above is that the conclusion is drawn at a population level. Why is that particularly relevant? It is relevant because the article also mentions that when there is less care some people are likely to feel like they are not getting what they need. The article suggests that's the point. The question is whether people are just "feeling like" they are not getting enough or are truly missing out on care. If the latter, then what? For the one person who is missing out on care that may truly be necessary, the change to less care does not make them better off. It is a reasonable fear that a person may be "the one" who has worse access and is adversely affected. However, if we only make changes if everyone in the entire system is guaranteed to be better off, we will never make any changes.
Also, when the author of the article compares certificate of need (a regulation by which health care providers and organizations must get permission to expand or to purchase new equipment) to things like a tax on "Cadillac health insurance plans", I find this to be a faulty comparison. Here is why.
Certificate of need regulations operate largely "behind the scenes". In other words, people don't see their effects very much on a daily basis. If individuals look into things they may still find it problematic that a governmental authority is dictating how much care will be available, but it doesn't affect their wallet every time they pay a premium. The Cadillac insurance tax (i.e. a tax on the most expense health insurance plans) directly affects the wallet of some group of individuals every time they pay a premium.
So, the comparison between a certificate of need regulation that rations care one way and other forms of rationing may not work.
All of this is just to say that those who are planning for how to ration care to control costs of health care in the United States without harming health at the population level need to be very careful to affect the smallest proportion of the population negatively as possible and to use rationing methods that (whether they are the most effective or not) attract as little attention as possible. The alternative is to education the American public about the relatively low chances that any individual will be harmed by the new policy and to convince people to accept that risk in order to enjoy the benefits of lower premiums and lower health care expenses if they are in the group that does not end up worse off as a result. It is all a matter of how our society comes to grips with tradeoffs in the future.
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