In the Nation's Interest

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Those who have followed the current health-care debate certainly have begun to hear the dreaded "R-word:" rationing. At this point, one side has attacked the other side's plan for threatening both to drive health spending through the roof, and to institute rationing to hold costs down. It would be possible to commit both of these transgressions at once, although they might seem under most circumstances to be mutually exclusive.

In any event, with frequent argument against rising health costs, it is not shocking to hear a counterargument against what many Americans conceive of as "rationing" - the denial of care to save money - as the inevitable remedy. Charges of rationing evoke images of long waits to obtain treatments such as surgeries, and even the use of such waiting periods in the cases of the old and the very sick to avoid ever actually delivering such expensive treatments. The Internet hysteria over alleged steps toward euthanasia shows just how provocative this specter can be.

An instinctive reaction of many typical Americans is that reducing health costs from their current level must involve denying some care, and that denying care inevitably will harm patients. President Obama and others have tried to explain that a significant proportion of current care in fact yields no benefit. Pioneering research by John E. Wennberg and his colleagues at The Dartmouth Atlas of Health Care has demonstrated that widely differing intensities of care in different parts of the country yield no significant difference in the quality of health outcomes. That is to say, physicians in some parts of the country tend to follow "practice styles" that involve more treatments and tests than elsewhere, but the greater intensity of care yields no identifiable benefit. Some health-care analysts have concluded that following the more-conservative, lower-cost practice styles could reduce total costs without reducing the true quality of care.

Moving from high-intensity practice styles - which yield no measurable benefit - to less-expensive, lower-intensity practices is not "rationing" in the sense that most Americans conceive of it. It might mean, for example, using physical therapy as a first resort before rushing to expensive imaging and back surgery. It might mean deciding that some procedures -like a form of back surgery, called vertebroplasty, for fractured vertebrae- ought to be used much less frequently than they are now, because there is limited evidence of any significant benefit. In many instances, more-conservative treatments also entail lesser risks of complications.

The reality that the nation can save money without harming health should provide some comfort to those who fear the specter of "rationing." There is plenty of room to trim back on cost before beginning to think about denying truly beneficial care. Still, a careful look at the practice of medicine today should yield a more nuanced view of the entire question.

A recent thoughtful column in the Washington Post by Manoj K. Jain, a physician, is a good place to start. Jain points out the many plain, but not obvious, instances when health care already is rationed, in the truest sense, today. There are two seriously ill patients in the emergency room, but there is only one empty bed in the hospital. The children of an 80-year-old smoker with end-stage emphysema announce to the attending physician that they have decided that their father will have a lung transplant. The list could go on, but the reality is that today's health care system has limited resources, and someone must decide where the resources will go. The person in authority confronted with such a decision must choose where those limited resources will do the most good. In the instances above, there is no time for society to build a new wing on the hospital, or for the physician to rush out and find another donor for a lung. And even if the resources were available to do so, there may well be alternative uses of those resources that would improve health care even more.

As we look forward, the nation will be confronted with a near-endless series of choices of how to use our limited resources to improve our nation's health. Should the last available dollar go toward extending the life of an 18-year-old, or an 80-year-old? What if a dollar can extend the life of one patient by a longer duration, but at a lower quality (and how do we measure "quality")? How should we evaluate treatments that can extend life, but at enormous cost?

The easy answer is that the value of life is infinite, and so we should simply have "more" for health care. But the same persons who want more for health care often also want more for early childhood education, or more for environmental protection, or more for national security, or more for one or more of a long list of other national priorities. We cannot have "more" for all of those purposes. Unfortunately, we have to choose.

Each of us may in the end make a different decision on any specific choice of priorities in health care. But the one point on which all Americans should agree is that we have no health-care dollars to waste. There is no excuse for tolerating needless treatments or duplicative tests. Protecting inefficiency in health care is denying care - or in different words, imposing "rationing." So those who decry the prospect of "rationing" through a reformed health-care system, and argue that instead we perpetuate the current system in which as much as one-third of spending yields no benefit, are arguing against themselves.

Commentaries are the views of the authors and do not necessarily represent policies of the Committee for Economic Development.

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