July 21, 2009

"Rationing" -- A Failure of Knowledge and Imagination

Once again we are treated to an ambitious attempt to pour new wine into an old wineskin -- an hoary old word is pushed toward a new meaning during a high stakes contest for our future. We must watch and perhaps gnash our teeth as the new meaning floats groundless in the air. We may watch hopefully, but experience suggests the outcome.... No matter how high the old is flung into the air, it simply floats up there for a while, flirting with the new meaning, then...gently settles back down right into its normal resting place.

A recent disastrous instance of this group self-flagellation was the ill-fated choice of the in-your-face word "nationalization" to refer to a public re-structuring of a failing major bank (similar to what the FDIC does, but on a larger scale). The word nationalization in no way aided a political move towards the needed process of restructuring certain major banks. It backfired, since it suggested something more than what was meant.

It was easy for bank lobbyists to paint "nationalization" as a form of "socialism." We are living with the consequences. Credit to businesses continues to contract in many instances where the business is sound and credit-worthy.

Today, we have "rationing."

The result is likely to be equally unfortunate for the public good.

Seemingly a rational necessity, we are asked to see the need for rationing medical care in a new light (for instance my own discussion of late-life choices a few weeks ago here in a brainstorming post).

But rationing of course has a popular meaning, just as nationalization had a popular meaning.

The popular meaning of rationing includes the expectation, which is firmly entrenched in about half of the population, that some reasonable types of care -- knee replacements for severely arthritic knees for example -- will simply be denied, or greatly delayed in long waiting lists, due to rationing.

In other words, to many people "rationing" means "you won't get any."

By using this word to refer to the generalization of making difficult choices -- contrary to its popular meaning of restriction of choice -- those seeking to open discussions of rationing are inadvertently helping to spread the "government will ration care" idea, just by helping the word become more commonplace in headlines.

But it is even worse than this. Unlike "nationalization" (restructuring) of large failing banks, rationing in the sense of making difficult choices about care in the Public Plan isn't even a good idea.


To presume rationing is an absolute inevitability is a failure of imagination. To impose it would be a failure of knowledge.

The problem with rationing is in certain presumptions.

The first obvious truth is that we do not have an unlimited ability as a nation to pay ever-higher health care costs as a portion of total national spending. A further truth worth communicating after pushing "rationing" into public debate is to point out that health care today is already "rationed" all the time, in one way or another -- either by explicit denial of benefits by insurers, denial of coverage, or by sky-high and escalating premiums.

But pointing out that health care is already "rationed" while talking of the need to "ration" is like attempting to clean up spilled milk as one continues to dump more onto the floor.

These two truths are not the only basic aspects of this issue. There is a consideration equally as fundamental and important.

Questioning any major idea is a necessary part of developing better solutions.

Rationing is a major idea. Therefore it should have been questioned more already.

But, better late than never, as they say...

First though, it may help at the outset to know that rationing isn't the only way to control costs of expensive treatments that have low success rates. A better solution is already presented here in the 3rd cost-inflation-control idea. As you can see from the link, this method I suggest is not "rationing" in the popular sense. The Public Plan need not rule for or against an expensive experimental gamble. Rather, it can simply allow individual choice, and offer a reasonable partial aid. Individuals receive information and partial help so that they can weight the costs and benefits according to their own unique calculus -- keeping their own integrity of choice and responsibility of choice.


Now...even leaving aside the misuse of language, rationing in the sense of making difficult choices on the public level is a flawed idea.


Because it violates a basic truth, or reality -- that we cannot successfully choose for others what they should value, and to what degree.

You cannot assign a value to a whether someone else should spend 3 hours a day playing a guitar for enjoyment, regardless of apparent costs.

You can't say they should, or that they should not. Nor can you choose what their priorities should be, nor what trade offs they should be allowed to make.

It is beyond our human mental ability to choose such large choices well for others.

It's simply a greater degree of complexity than we are able to cover.

We don't know whether someone might prefer an exotic and chancy therapy or treatment in a last-ditch attempt where they would have to pay $15,000-$40,000 out of pocket, or pay for an expensive supplemental insurance policy that covers such procedures. We cannot make such choices for individuals, one way or the other, even if we are committed to offer a defined, precise, partial support for less-reliable or less-cost-effective treatments that requires public plan payment of part of the cost.

No 2nd party has the knowledge to place a value on 3 months or 6 months worth of your life, regardless of your age.

But...you have that ability.

Individuals who choose more heroic end-of-life care have every right to choose such and pay a significant part of the cost or high insurance premiums. Individuals who choose exactly to have no heroic end-of-life care at all have a right to a lower premium, and thus some extra freedom of time and money for different goals and values in their lives.

So, the solution to the seeming problem of public Rationing is not to.

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