Health-Care Rationing: Bring it On

Since the debate over health-care reform has brought the problem—and threat—of rationing to the fore, let's give a tip of the hat to Dr. Henry Friedman, professor of neuro-oncology and codirector of the brain-tumor center at Duke University Medical Center. That's where Ted Kennedy had last-ditch surgery last year after he was diagnosed with glioblastoma. In an article last Friday in The New York Times, Friedman spoke of the extraordinary and expensive measures the senator and his medical team took, including the surgery. "If you have the insurance to come to Duke, no problem," Friedman told the Times. And if you are uninsured, if your insurance does not cover such surgery, or if Duke is not in your plan's network, and you do not have a few tens of thousands of dollars to pay out of pocket, then "we will work with [your] home physician to give them our expertise," said Friedman.

Translation: you don't get to have brain-cancer surgery at Duke.

And that, my friends, is the rationing we have today: determined by insurance companies and ability to pay.

I don't mean to single out Duke. It is the rule, not the exception, that doctors and hospitals provide care based on ability to pay. Nor do I mean to imply that with health-care reform we will all be able to go to the top medical centers and get any treatment we want. The point is simply this: rationing is already here.

It is time, then, to move beyond the ignorant and duplicitous debate over rationing—"ignorant and duplicitous" because many of those opposed to the health-care-reform bills wending their way through Congress pretend that rationing is not happening in the current system or, to be charitable, are not aware that it is—to an examination of what I'll call "smart rationing." That is, let's figure out what treatments and diagnostic tests make a difference to people's health and longevity, and which are insanely overused to no good end. The latter is what we need to ration, restricting their use to the patients and conditions where they can make a difference or abandoning them altogether.