Rationing health care: will it be necessary? Can it be done without age or disability discrimination?

• Author: Callahan, Daniel

Rationing Health Care: Will It Be Necessary? Can It Be Done Without Age or Disability Discrimination?

For well over two decades the United States has made a strong effort to contain the rising costs of health care, but to little avail. Those costs have seen a consistent inflationary increase of 8-10% a year, about twice the rate of general inflation, and no end is yet in sight.(1) That increase has put enormous pressure on government entitlement programs and on employer-sponsored insurance. At the same time, the number of those who have no health insurance at all has steadily increased, to nearly forty million.(2) We are faced with pressures that move in diametrically opposed directions: to find strong and effective ways to hold down the costs of health care, and to increase expenditures in order to provide more equitable access to those who cannot afford it. Can these contradictory needs be met? Possibly. We will need to provide a guaranteed minimal level of adequate care for everyone, regardless of ability to pay, and a set of limits to health care coverage to make it economically possible to do so. One way or another, we will have to ration health care: either because we will not be able to afford uncontrolled inflationary increases in costs, or because we will need to do so in order to assure an equitable system of care.

The argument in this article is that, if we must ration or otherwise limit health care, we would be wise to set those limits by the use of categorical standards when possible, rather than setting limits on a case-by-case basis. "Categorical standards" is used to mean the employment of visible, objective, universal criteria that can be applied to all (or most) individuals and that do not require complex interpretation to be employed. The requirement that a person be sixty-five to be eligible for Medicare, or sixteen to drive a car, or fifty-nine and one-half to take money out of an IRA account without penalty are examples of categorical standards. A limit based on a categorical standard might be, say, a denial of some forms of health care beyond the age of eighty or eighty-two for those covered by Medicare, or denial of access to an intensive care unit to those who do not meet certain announced and public standards of probable benefit from such access, or denial of neonatal care to infants below, say, 750 grams. For the sake of some simplicity in the discussion that follows, this article will be limited to the use of categorical standards for government entitlement programs rather than for private insurance programs (though similar standards could be used there as well; and the author hopes that private programs would go in a similar direction, to reduce to a minimum the gap between rich and poor).

Do we in fact need to consider rationing in this country and rationing stringent enough to justify the use of categorical standards? This is not the place to develop the full case for rationing, but there are some powerful considerations that make it likely, if not now, in the near future. The first consideration is that we have an aging society, and the combination of an aging society and the increased use of high-technology medicine on an aging population is a recipe for unlimited and unmanageable costs. The evidence is good that age by itself does not drive up health care costs, but that age combined with the application of expensive technological medicine and improved services does.(3) Since the human body ages and is finite of its nature, there is literally no logical or scientific end to the possibility of spending more and more money trying to defeat aging and death.

The second consideration is a more general one. There is no end to the possibility of spending more money trying to defeat illness, disease, and death at all stages of life. If we define the goal of medicine as the meeting of every individual health need - as is customary in our country - then the need for curative medicine is an unlimited one. We can now save babies down to 500 grams, but we can go on to try for 400 grams, and then 300, and then 200, and then we can take on the high rate of spontaneous abortion and miscarriage if we choose to do so. With other categories of patients, there have now been cases costing $1.5 million and $2 million. The routine costs of liver transplants are more than two hundred thousand dollars ($200,000).(4) Medical progress, then, is unlimited in its potentiality to give every life, however fragile, a few more hours, or days, or weeks. In addition, those lives that are now resistant to that possibility may well - if we invest enough in research - be saved in the future.

This is only to say that, given medical progress, we cannot meet every individual "need." We have, for one thing, made the line between need and desire systematically fuzzy. If we define one goal of medicine as meeting the need of patients to live, then we "need" whatever technology it will take to make that possible, whether it be penicillin for many or an artificial heart for a few. But since the body is inherently prone to age and deteriorate, there is no limit to the possibilities of trying to meet the "need" (if we so define it) of people to avoid death. Another consideration is that, in our quest to meet each and every individual need, we increase the gap between the least expensive and the most expensive patient. That is why it is possible to spend up to $2 million on an individual adult patient, and why one study showed that corporations have seen a 30% increase in cases costing more than one hundred thousand dollars ($100,000) in just a few years.(5) If we have an unlimited commitment to meeting individual need, then the logic of modern medicine is to drive up the costs of the most difficult individual cases; there is no limit to what we can try to do to pull those cases through.

To those considerations, we should add one more of great importance. The more successful medicine is in meeting our present individual needs, the more certain it is that we will devise new needs to take their place. Human health needs are not fixed, but are subject to individual and cultural definitions. No one thought, one hundred years ago, of a failing heart as pointing to the "need" for a heart transplant. But that is the way we now think of them, and to that we have added the additional "need" of artificial hearts for those cases where transplants are not possible. The government is thus sponsoring research ($250 million to date) to eventually make that latter development possible.(6) Is it wholly unrealistic for us to imagine, thirty years from now, a person dying of heart failure at the age of ninety-five and claiming the need for an artificial heart? And dialysis if his kidneys next fail, and cornea transplants if necessary to help him continue seeing, and the expense of the new drug that will be then have been developed for his Alzheimer's disease?

My conclusion is a simple one: it has become, in principle, impossible for us to meet individual curative need - it is an intrinsically open-ended concept, subject to no inherent limitations at all. A health care system that defines its goal or ideal as that of meeting all individual needs can neither achieve that goal, nor afford increasingly more money trying to do so.

Medicine will forever be on the edge of two great and endless frontiers: One of them is that of aging, for there is no end to the possibilities of trying to extend the lives of older persons; and the other is the frontier of individual cure, for there is no end to the possibilities of trying to cure illness and save life. Both of...