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Viewpoint: Rationing of health care is on the horizon

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Anyone who is even marginally aware of today's public policy controversies knows something of the sweeping health care "reform" bills now under consideration at the federal level.

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Although no final action has yet been taken on any of these proposals, it is obvious that any one of them, if enacted, would greatly expand the federal government's role in the health care sector of the American economy. They would also require either large tax increases or, alternatively, significant federal deficits. Or perhaps both. And there is, in addition, the threat of mandated public funding of abortion. And the specter of bureaucratically imposed rationing of health care.

I know, of course, that many will dismiss the rationing threat as a scare tactic intended to discredit what they consider to be much needed "reform" legislation. Moreover, some may even claim that a government managed health care system, rather than rationing health care, will make more and better care available to more people at less cost than does the present system. They will further contend that the American health care system now unofficially "rations" health care, favoring the affluent while discriminating against the less fortunate. But a word of caution: any "rationing" of medical resources in the current American system is, arguably, less intentional, less pervasive than the rationing to be found in many nationalized systems.

There are several ways in which socialized systems can and do ration health care.

In Canada rationing stems from stringent cost containment policies which limit the supply/availability of health care resources, the predictable result of which is delayed or minimalistic treatment, especially for patients with serious medical problems. Or, alternatively, there is the export option, i.e. the practice of shipping Canadian patients to the United States for the specialized health care that their own ostensibly "free" system does not readily provide. Thus, women with high risk pregnancies often seek care in Seattle.

Patients needing hip replacements often go to Cleveland, Ohio. A significant number of northern Minnesota physicians, we are told, treat Canadians who pay cash for medical care that they cannot obtain at home (or that they can only obtain with great difficulty). Moreover, each year one out of three Canadian physicians reportedly refers a patient to an American health care facility.

Rationing in the Canadian system, can, however, be described as "soft" rationing, the inevitable by-product of governmental attempts to reduce health care costs (the rallying cry of many of today's U.S. "reformers").

But soft rationing, however undesirable, is quite benign when compared to the "hard" rationing now advocated by many influential bioethicists, politicians and others. This type of rationing envisions policies requiring (or at least strongly encouraging) health care providers to base treatment decisions on bureaucratically imposed cost-effectiveness, cost-benefit or "outcome" criteria.

One notable example of "hard" utilitarian medicine is to be found in the policies of the British National Institute for Health and Clinical Excellence (NICE). This group, a "special health authority" affiliated with Britain's national health system, has developed what it calls a "quality adjusted life year (QALY) metric and a "health related quality of life" (HRQL) metric. These two indices are then formulaically combined to determine whether a given treatment or medical procedure is or is not "cost-effective".

For example, the QALY/HRQL formula would probably "demonstrate" that heart surgery for a 76-year-old man would not be cost-effective. After all, the old man has only a few more years of life while the same or similar surgery, if made available to a young person, would provide many "life-years" of benefit. So the old codger gets aspirin therapy and the youngster gets the surgery. Moreover, some patients who score less than zero on the quality index might get no treatment whatsoever (or maybe the equivalent of the proverbial "shot in the arm" ).

Although I do not know the extent to which NICE has yet been able to shape day to day British medical practice, I do know that its crassly utilitarian view of medicine is rapidly gaining widespread acceptance, both here and elsewhere. In this regard, much of the language in the bills now before Congress would, I think, make the people at NICE very happy. Very happy indeed.

St. Martin is a Woodbury resident.

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