The consequences of covert rationing
While devising a fair system of open rationing would be difficult and painful, the consequences of covert rationing are even more terrible.
Consider the most obvious result when healthcare has to be rationed tacitly. Human nature being what it is, interest groups (doctors, hospitals, insurers, biomedical industry, and government) proclaim that the changes in healthcare occurring today are good and represent their single-minded efforts to become more efficient, patient-oriented, and quality-driven. Meanwhile (again, human nature being what it is) those same interest groups compete among themselves for a limited healthcare dollar. This competition is fierce because it is driven not only by greed but also by the threat to professional survival. Next to a threat like this, the healthcare being provided to the public (the entity for which the healthcare system ostensibly exists in the first place) becomes almost an afterthought. So that limited healthcare dollar, instead of being used to bring about the greatest good for the greatest number, ends up in the hands of whichever interest groups are best at playing the game.
But the covert rationing of healthcare is more than just unfair, deceptive, and harmful to individuals; it is destructive to our entire society. By pretending that we are not rationing (and that there is no need to ration), we are bequeathing to our children and grandchildren an enormous, destabilizing fiscal burden.
More important than that fiscal burden are the political and social burdens we are creating for our children. To keep the rationing of healthcare covert, we are engaged in a cascade of compromise and self-deception that threatens the underpinnings of not only our healthcare system but also our American culture. Such self-deception is apparent in every aspect of healthcare: in the restructuring of the business side of healthcare; in the changes in the legal and regulatory climate; in the design, justification, and interpretation of medical research; and ironically, in the growing call for expanded patients’ rights. These compromises will have destructive effects that go beyond withholding useful healthcare from some of those who need it. Taken together, these compromises constitute a powerful attack on an ideal that is essential to our American society - the ideal of individual autonomy.
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We ought to have learned by now - from the American Revolution to the Civil War to the twentieth century struggles against fascism and communism - that maintaining individual autonomy in the face of the needs of society can never be a settled issue. Each generation of Americans must grapple with this question. (The argument over the Patriot Act, which offers to protect society, but potentially at the expense of abrogating important individual rights, exemplifies this ongoing struggle.)
Healthcare rationing strongly challenges the autonomy of the individual. If we ration, whether overtly or covertly, we must withhold from individuals for the benefit of society. But while it is possible to construct a system of open rationing that balances individual autonomy with the needs of the whole (as we will see later), it is not possible to do so under covert rationing. When we ration covertly we abandon the individual, often as the first step, without any discussion, and without realizing what we’re throwing away. This is the ultimate price we pay as a society when we quietly, subconsciously collude with the covert rationing of healthcare.
In the next several posts we will examine just how it is that Quadrant III healthcare poses such a profound threat to us as individuals and to our society. We’ll begin with a survey of the great engine of covert rationing, managed care, as practiced by modern Wonkonians and Gekkonians.
