Two stories, both summarized in a recent issue of the ACC News Digest, serve to illustrate the inexorable increase in the rationing of health care that is coming. I say “increase,” because we’ve always rationed in a blunt, inefficient and relatively mindless way that allows us to perpetuate the illusion that we’re above making value judgments when it comes to allocating health care resources.

The first report, from the Los Angeles Times (9/1, Helfand) reports that “Gov. Arnold Schwarzenegger’s (R) administration has quietly allowed hefty increases for thousands of sick or jobless Californians who must rely on expensive safety-net coverage.” It goes on to cite that state regulators have given insurance companies permission to raise maximum premiums for most of the 20,000 Californians who depend this form of coverage.  Some will have to pay an extra $7,500 annually, “pushing their bills to nearly $25,000.” Reportedly, the increases are “the result of a move to correct a much-criticized system for calculating maximum premiums that had led to unpredictable cost fluctuations.”

The second article cited, from USA Today (9/1, Marcus), reports “many physicians say an increasing number of patients are getting involved in decisions about their medical care, including medication choices, whether they need a specialist, and especially whether they need expensive diagnostic tests, which some health economists say are driving up the cost of health care.” It goes on to say that “some doctors find the newer ‘empowered’ patients taxing,” while others “welcome involvement and questions, especially since they recognize more patients are ponying up for larger co-pays or are uninsured and covering entire medical fees themselves.”

So, in the insurance arena, as costs inevitably spiral upward, premiums will too. No amount of reform magic can change this. And as the percentage the patient must pay out-of-pocket follows along, patients will begin to make decisions about the direction of their own health care. It’s good to bring the patient back into the loop to aid in cost control, especially since some interventions are of marginal benefit relative to the expense, but it can be a double-edged sword: when a patient decides against a preferred course of more costly prevention or therapy it may leads to disaster down the line.

As I’ve said before, the only real gains we can expect going forward will be in increasing competition and cutting waste from the system, and some of this will involve making value judgments to minimize harm. Regardless of the path we as a people choose to take, expect to see a lot more rationing, rational or irrational, in the future.

The marketplace is a stern taskmaster and will not be denied.


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