Health Care Resource Prioritization and Rationing: Why Is It So Difficult?

Dan W. Brock Health Care Resource Prioritization and Rationing: Why Is It So Difficult? T h e p r i o r i t i z a t i o n o f h e a l t h c a r e r e s o u r c e s a n d r a t i o n i n g i s a paradigm example of difficult choices, and yet one m ight well wonder why. Individuals are continually forced every day to prioritize their own resources, deciding w hat to use them for and w hat to forego. The process could not be m ore familiar. Since our wants typically outrun our resources, and although we may regret w hat m ust be foregone, we learn to make the choices and move on to the next ones. So why is the very idea of prioritizing and rationing health care resources so trou­ bling and controversial? Americans are deeply ambivalent and inconsistent about health care rationing. On the one hand many like to pretend that it does not take place, but they fear being denied beneficial care, in particular paym ent by their health insurance plans for care they need. If rationing does not take place, of course, there is little to fear. On the one hand, m any say that we are a rich country and have no need to ration health care, but they resist the rising costs of health care, particularly w hen they result in greater out-of-pocket costs to them . On the one hand, m any say that life is precious and money should not enter into deci­ sions about medical treatm ent, but on the other hand they resist the ever increasing proportion of both our national w ealth and their own social research Vol 74 : No 1 : Spring 2007 125 w ealth that goes to health care. And on the one hand many recognize the need to lim it the use of some health care, but resist those limits w hen they are applied to them or others about whom they care. Now these inconsistencies m ight sim ply reflect a perfectly common and understandable desire to have more of a valued good like health care, but not to pay m ore for it. For goods that we m ust purchase in a m arketplace, we soon learn th at this is not a desire th at can be satisfied—if we w ant more, we m ust be prepared to pay more, and so we m ust decide how m uch that m ore is w orth to us in comparison with other uses for our resources. Most Americans, however, do not pay out of pocket the full costs of the health care they receive, but instead have m ost or all of the costs of their health care paid through health insur­ ance. So unlike goods fully purchased and paid for in the marketplace, we do not bear the full, often most, or sometimes even any, of the real costs of the health care we consume. In the extreme, if we can get it for free, it is hardly surprising that we do not support rationing w hich will have the effect of denying some health care to us. Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who w ant and could be benefited by th at good will not receive it. This allocation or rationing can take place by m any means. The use of a m arket to distribute a good is one common way to ration it, since attaching a price to a good or service is one way of allocating it in conditions of scarcity and results in some who would w ant it and could be benefited by it not getting it. One reflection of our ambivalence toward health care rationing is seen in our resis­ tance to having it distributed in a m arket like m ost other goods: m ost Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another...