Q: Will the proposed health care reforms that include a government insurance option lead to rationing of medical services?

The Debaters

printable version

Peter Singer
Professor of Bioethics, Princeton University

Michael Tanner
Senior Fellow, The Cato Institute

Commenter: Leon
Our health system which has as its primary goal the optimizing profits for the insurance industry. It is inherently in conflict with achieving the societal goal of health security and healthy outcomes for everyone. It's time to serve the needs of larger society and not narrow corporate interests.

Commenter: W. Moff
Tanner says, "The real health care debate, therefore, is...whether people will still be able to purchase a procedure even if the government denies coverage for it."

I don't think that's the real debate at all. Much of the reform effort is for people who cannot afford or qualify for ANY insurance. The idea of purchasing extra coverage is laughable. Tanner's argument is pitched only to the wealthy.

Commenter: Ron Ward
COME NORTH...to CANADA or beyond! I fact, all secular, northern democracies know'what you do for the least of mine'is best for the rest and that greed and self interest is fatal to any community. STOP worshipping God with an L in his name.
STOP listening to the disinformation that greed merchants sell you and ask why the even the UN says the 3 best countries to live in are in the snowbelt...including CANADA.
Bottom line; You can become as prosperous as you
like, your children and you are health and education protected for life and you can keep your US citizenship ...in case you ever think I've lied to you. (several millionb from the underground railway to Viet Nam and Iraq war protesters are still here and loving it!

Commenter: Alyson Slutzky
I agree with Peter Singer that we already have health care rationing. As an oncology social worker, I've had many patients who cannot obtain medications due to not being able to afford their co-pays, or having to pay up front out of pocket for their Rx, and then submit their receipts. They don't have the money to afford covering the Rx 100%, so they can't obtain the medications. I've also had patients who thought they had health insurance, but when they were diagnosed with cancer, they found that they had minimal insurance that really only covered a few doctor visits a year. These patients had to apply for charity care in order to obtain medical care for their cancer. The states pay for charity care for those who don't have health insurance or adequate coverage. It's a misnomer that we aren't currently paying for the uninsured or underinsured, as the states are all covering these people through the state charity care budget line.

Commenter: Alex Censor
This debate is named misleadingly. We already do ration medical services, very seriously so. We just hide the fact that we do so.

The reality that no country can afford to pay for all remotely, or even "reasonably" possible worthwhile medical help makes it inevitable that there's rationing. In an ideal world every person might, for example, get an MRI every year as part of an annual checkup, maybe every 6 months. Doing everything that can be done for everyone every time would bankrupt us very quickly. If we pretend, as presently, that we don't ration while doing it we will do it irrationally and unfairly.

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How can health care reform "lead" to rationing when it's already here big time?


For the most part we ration it by cost, with the wealthy or the very few lucky or rich enough to have good health coverage with a payer that is patient-friendly getting to the head of the line, somewhat behind them in SOME cases are the very poor who are eligible for the increasingly-difficult-to-get-into state plans such as MediCal, and at the back of the line are the lower middle-class and the working poor, such as the millions of uninsured working Americans.

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Anecdotes of delayed care in the Canadian system are touted as demonstrating the terrible effects of rationing.

There is always (or at least I should say "often") a grain of truth in such propaganda distortions.
In this case the claim by the opponents of real USA health care reform that under socialized medicine and the Canadian health care system in particular
that people have to wait unreasonable amounts of time for medical care with
terrible consequences.


In fact there undoubtedly are some instances where someone has been delayed,
badly delayed, in getting medical care in the Canadian system.

Those anecdotes don't address that this happens far more often to US citizens.
I was delayed care for my enlarged prostate for 3 years while I waited to be Medicare eligible to be able to afford surgery -- as, like millions of
Americans I had no health insurance and the surgery would have cost over $40K. And I was earning about $30K per year. As a result of delay my kidney
Perforated and I could have died.

Millions more are delayed or denied care here while arguing with their insurance companies.
These, particularly the uninsured or weakly insured, who put of going to a doctor here because of costs, don't show up in formal statistics of delayed
care, but here's an estimate from one study:
In 2007 14% of people in the USA reported an occasion when they believed they needed care but did not because of cost.
See --
http://budget.senate.gov/democratic/testimony/2007/1037_Collins_universal_hlt_insurance_testimony_06-26-2007.pdf

This does not include those who under our system _did_ go to the doctor but, like my example were unable to afford the recommended treatment, or were delayed in getting care while arguing with their insurance company or even just waiting for pre-approval, nor the ones flatly denied care that was covered by their policy because the insurance company dug back in their records to find some technicality to cancel their policy.

Any anecdotal instances of Canadians getting delayed care are swamped by these numbers.

Commenter: Heidi
A non-partisan CBO, as well as existing Medicare and Medicaid, have proven that the costs are far greater than estimated when the government provides these services. If our country is bankrupt and inflation soars - how will the government pay for these wonderful heart-felt programs? The quality of life would plummet for most Americans. Like it or not, the free market - with improvements - is the only thing we can afford, now and in the long run.

Commenter: Tom Wieliczka
You're afraid of future "Rationing"? Have you read today's headlines?


Aetna Forcing 600,000-Plus To Lose Coverage In Effort To Raise Profits

http://www.huffingtonpost.com/2009/12/04/aetna-forcing-600000-plus_n_380130.html

If that's not proof that Insurance Companies ALREADY do Rationing, then it's time to take your head out of the sand!!!

Oh, and the reason they are cutting over 600,000 people from their medical insurance is for PROFITS.

Shows who they are more concerned about - the shareholders and the hell with the customers!

Tom

Commenter: Elkan Katz
Singer is talking about the reality of insurance companies denying coverage. They have whole depts. devoted to this. Tanner is talking about a possible, but not likely, negative outcome. Insurance companies should face real competition that a public option would provide. It would be better for a govt. agency to decide certain medical procedures don't merit coverage because they are ineffectual than an insurance company denying coverage because it hurts their profits.

Commenter: John Slonczewski
Peter Singer wins. That a large proportion of people in the US should be without adequate healthcare is unacceptable. Access to adequate health care should be a basic right just as in all other advanced countries. The fact that it is not is a national shame.

Commenter: RealWorld
No, providing health care like 'another public service for the public good just like fire' would not solve anything. Most of this nation is NOT covered by fire protection. People living in cities need to get outside more and see the rest of America. Many folks in 'fly-over' States still provide their own drinking water, waste management, fire protection, etc. Some provide their own electrical service. The people who chose to live with malls and signal lights have a different reality from the rest of us. Health care out here is a personal responsibility. Social health care may make sense in urban ant-farms, but has little benefit in the rest of America. We are already 'rationed' by distance and mostly treat ourselves.

Commenter: RealityCheck
Yes, rationing will exist because language in both Bills does nothing to 'prevent' or 'forbid' it. Remember silence in Bill verbitage actual green lights the action, after P.L. codification and during final regulation (CFR) creation. This is a standard practice of congress and ignored by many Americans. Silence is approval. If you want NO rationing, then the Act had better state it in plain terms.
Like: "Under this Act all federal departments, agencies, employees, agents, and representatives shall be forbidden from participating in any activity, discussion, group, or panel; which purpose or effect would be to ration, restrict, proportion, limit, or develop quota on medical care, treatment, procedures, or payment."
remember, stupid is as stupid does...

Commenter: Howard F. Harris Jr
Health care should be just another public service for the public good just like fire

Commenter: John R. Goodson
What concerns me is that there are consultants inside the proposed health care plan that would ration health care. These people would deny medical care to patients with out thier input to save on costs. This could even extend to people with physical or mental handicaps.

Commenter: Greg Chimenti
Rationing is a pejorative for sharing, i.e. citizens agreeing to a more "equitable distribution of wealth" in their communities or in their nations. It was FDR who is most closely associated with that idea and its implementation, not Mao, not Stalin.

Commenter: Irvin Duclos
Doesn't proexisting conditions bring back the old National Socialst argument about the aryan race?

Commenter: Freedem
Let's see verifiable fact versus made up "possibilities", which "wins"?

The Key fact is that the Cato Antisocial Ideology has gone horribly and provably wrong, especially in the past year or eight. Without some form of regulation to keep criminal behavior away it will become the dominant meme. That sort of Socialization is what Cato's funders fear most, and why we need to really take our country back (electing Obama was not enough).

Commenter: Cory Carroll, M.D.
Mr Tanner made the statement "Providers would be forced to recoup that lost income by shifting their costs to private insurance, driving up premiums". The statement that I, as a physician, can "recoup" my costs from a massive corporation is extremely naive. My reimbursement – from both governmental and private companies has been essentially flat for the last decade and I have no real power in negotiating fees. What I know about the for-profit insurance market is they, by law, put the financial interest of their shareholders first. That system is hurting physicians (mainly primary care) and patients much, much more than government. For this doc I'll put my hope in a governmental plan that has the best chance of putting patients first and more likely to sustain my practice.

Commenter: Robert
When the government run system drives the Dr's and Hospitals to leave the practice of medicine due to low reimbursements the only place you will be able to get medical care is from the government. When the funds to provide the care run out the government will limit the services available. It happens now in Canada and England. It is a misconception that you can get the same care for less. And if the government says that it can save money from waste within the present system lets go after this fraud, waste and abuse in the present system just to see how much can be saved, I do not think that the government can stop any of it; they have not done it with ANY programs in place in the past.

Commenter: Richard Heckler
Rationing will not occur that is a scare tactic. There is no substance to that allegation.Actually rationing has been occurring under our present system for decades by way of patients being denied and patients not being able to afford medical insurance.

HR 676 for instance will insure all of america thus providing more operating revenue to the health care industry. Thus more medical people can be hired.

Rationing will not occur because coverage such as HR 676 will eliminate NOT necessary medical coverage and will eliminate tons of administrative costs now associated with the current most expensive medical insurance coverage in the world.

Face it the USA cannot afford the most expensive insurance in the world. Rationing is NOT experienced in Canada and will NOT take place in the USA under HR 676.

Commenter: Thomas
who responsibility is a person's health?
the individual or the government?

It should be the responsibility.
Then if it is the individual, where does the community or government comes into the picture?

when a person is irresponsible...taking illegal drugs that destroy him or have improper sex, we as the community should not be paying for his mistakes or immoral acts.

the government's role should be keeping the healthcare cost low by enacting malpractice reform, increasing supply of pharmaceutical drugs and equipment, increasing competition through opening up the markets across state borders.

It is wrong to vilify the insurance companies...because premiums are based on loss ratios.

the presidency and the Congress are leading the people the wrong. We should consider everything from single payor...putting a cap on malpractice awards..limiting malpractice limits...

Commenter: PF Moreno
According to Paul Krugman with the New York Times, Obama's health care plan will require everyone buy a health insurance policy. Krugman thinks this is a good thing http://www.nytimes.com/2009/08/17/opinion/17krugman.htm

All along the health insurance companies have been volunteering to give up pre-existing conditions, and enrollment denial, if they can get a law that will lock everyone in.

Wendell Potter says the bill in the works looks like the "Health Insurance Company Profit Protection and Enhancement Act." http://www.youtube.com/watch?v=GBFKkXDSKWw

Former Reagan economist Paul Craig Roberts says the free market in health insurance is imaginary and the only way to fix things is to take the profit out and go to a single payer system http://counterpunch.org/roberts09142009.html

I'm with Paul Craig Roberts.

I would also like to add I worked at Regence BlueCross BlueShield for four years: one in customer service, two as a claims adjudicator, and one as an assistant manager.

Commenter: Roger H Strube MD
Before rationing gets on the table several realities must be recognized. First, up to half the recommendations made by physicians using the memory based subjective dicision making process are in error. Second, it is impossible for the consumer (patient) to judge quality care decisions from bad decision making. A consumer driven "free market" approach will not work either to improve quality or drive down cost and will, in fact, make things worse. The central debate should be about the medical necessity of care ordered by physicians and/or desired (wanted) by patients. We are many years away from needing to place rationing on the table if we properly address and reduce unnecessary medical care.

Commenter: Wayne in Canada
This Canadian observer of the healthcare "debate" in America can't take it anymore! I encourage Americans to have a serious debate, not a fabricated one based on the arguments of the lunatic fringe that has hijacked the Republican Party and, quite frankly, scares the crap out of the rest of us. If I can do something to bring about even a small measure of sanity to a discussion of government's role in providing healthcare, then perhaps I'll sleep a little better in the knowledge that I haven't stood on the sidelines while your country self-destructs. So here's an outsider's viewpoint on what is perhaps the most critical issue facing America today, not least because you run the risk of bankrupting yourselves - and the rest of us in the process - if you do nothing but tinker around the edges, but also because this is of such fundamental importance to what America claims to stand for: justice for all.

Americans seem to have an unhealthy and unrealistic problem with labels, choking on words like liberal or socialist as if they mean something they are not. Thus my frustration with people who do not think before speaking. True liberalism has a long history of reliance upon the individual. The word "liberal" itself implies "laissez-faire", which is just another way of saying capitalism, but with the necessary constraints in place to minimize the potential for abuse. And socialism does not mean the government makes every decision for you. (Thus the incomprehensible myth about Canadians not being able to choose their own physician. Canadians can choose to see whomever they wish - they can even request to see a specific specialist but usually defer to their GP or family physician for referrals.) Rather, socialism is about the social contract between government and its citizens. Government will provide the safety net that will not allow anyone to fall through the cracks. But ignorance prevails in what passes for political discourse in America today. Granny will be euthanized, government-run healthcare will result in rationing (as if private insurers do not ration while padding their pockets), abortions will be mandated. But don't touch my Medicare! Or my Medicaid! Or my Social Security! ALL government programs! This kind of obfuscation borders on the insane.

Why isn't America prepared to do what works in the rest of the industrialized world - and works rather well, I might add, if you'd care to ask the British, the French, the Dutch, the Scandinavians, the Australians and, yes, even the Canadians? Are you so arrogant to believe that the American way must be better, even if nobody else in the world wants your kind of healthcare system? Those countries tax their citizens considerably more than you do but then provide so many of the basic services America denies to its own citizens, services those other "socialist" countries long ago decided should be considered rights, not privileges with access only to those of means. America has a huge tax base that could quite easily share the burden of providing access to healthcare for all its citizens, if only you weren't so keen on "having it all and having it now" - an attitude that contributed in large part to the economic crisis the whole world is struggling to get out of right now. There is, quite simply, no social contract in America.

You are constantly citing your "founding fathers" (who, of course, were so wise as to anticipate every seismic cultural and societal shift that would occur in the next several centuries) as if they could be counted upon for perpetual and uncritical guidance.

But what about Jefferson's exhortation in the Declaration of Independence:

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.

It's hard to pursue "happiness" if you can't afford health insurance. And if you're entitled to "life", then why are patients, even those with health insurance, denied care or forced to sell their homes because they can't afford deductibles or co-pays? If there is anything "self-evident" in the U.S. healthcare system, it is that citizens are not created equal. If you were unlucky enough to have been born on the wrong side of the tracks or to have lost your job and your employer medical benefits, then it's just too bad, isn't it?

On a recent broadcast of the NewsHour on PBS, Sen. Bob Corker (R, Tenn) concluded an exchange with Sen. Amy Klobuchar (D, Minn) by saying that America needs to preserve the best healthcare delivery system in the world. What galaxy do these people come from? Evidently Sen. Corker hasn't been to Cuba, a country whose healthcare system puts America's to shame. Yes, that's right - CUBA! Now that's gotta hurt.

I've come to the conclusion - and do forgive the language - that America has no balls. You send your military anywhere you want to play tough guy - usually without success, at least since World War II, except in really important places like Grenada - but you can't regulate greedy banks and insurance companies. America is gutless, America doesn't care about its own poor, and America will sink in its own stew of greed, corruption and a self-serving attitude of "I'm okay, what's your problem?" Some individuals can and do care but they are quiet voices in the wilderness, voices that do not carry guns or Bibles but plead for common sense. America is going down the toilet. If only you weren't going to take the rest of us with you. If I seem harsh, it's because I can no longer stomach the ignorance and stupidity of people who refuse to think. Sadly, America deserves what it's doing to itself. The rest of the world is not amused. But at least the rest of us need not worry about pre-existing conditions, co-pays, deductibles and even health insurance premiums. We just pay our taxes, taking great comfort in the knowledge that our healthcare systems take care of us - and rather well, it would appear - while we take care of each other.

Commenter: Nancy Straus
The private insurance companies have had years to get their act together, however, what they have given us is an inefficient, fragmented, dysfunctional "system". It is time for a government option.

Commenter: PJ
People should draw a distinction between cost-benefit analysis and true rationing. Rationing would mean that a cap, either by number of procedures or funds available, would result in waiting lists. The lists might be prioritized based on medical need and anticipated outcome, or perhaps not. This doesn't seem to be what has been proposed by anyone.

The other mechanism of cost control would consider the cost-benefit trade off of given treatments for a particular circumstance. Treatments which don't have strong evidence of outcomes proportional to cost would require that a patient pay for more or all of the treatment. If considered a form of "rationing," it is still very different from the other form.

People should at least consider this difference before deciding if they oppose one or both.

While arguments in favor of the cost-benefit form of "rationing" migh seem very strong, one valid concern is that in some circumstances paying for treatments that may now have seemingly low benefit to cost (extending a cancer patient's life by 1 month) may be a step in the process to developing more advanced treatments that are unquestionably worth the money.

Mr. Tanner, your argument against a public plan would be much stronger if you (or others advocating this view) would identify business leaders/owners that will go on record stating that they would likely drop private plans if a cheaper government plan were available. I have owned one company and woked for many others that offered health insurance not because it was required but because it was viewed as a mechanism to attract and retain talented employees. The cheaper option for the companies would be to offer no coverage. Having a business owner/leader who currently offers good quality private insurance explain why they would choose to force employees into a plan they didn't like would go a long way to stengthening your argument.

Commenter: Greg Gordon
Of course the proposed government health care plans will involve rationing, and any politician who denies it is a liar. A government appointed panel will decide who gets expensive treatments and who dies. There will be many patients who need experimental cancer or HIV treatment who will be denied services. And without the profit motive, many health care corporations and pharmaceutical corporations will have no incentive to put money into research for new treatments. Medical technology will stagnate under a government-run health care system.

Commenter: Cathy Lester
Mr. Tanner thibnks the government could keep its premiums "artificially low." That's rich.

A government plan would keep premiums reasonable. It's the insurance companies that are keeping them artificially high.

Commenter: Phyllis
It seems obvious that we now have rationing by insurance companies and that whatever plan is implemented, we will continue to have rationing. It also seems likely that rationing decisions will be more equitable if done by the government, which presumably will have disinterested medical doctors make the ultimate decision, instead of corporate employees competing for bonuses. No more denying care based on likelihood of the patient's suing, or just to see whether the policyholder will passively accept the first denial.

Commenter: Sandy
The public plan HR676/S703 before Congress requires that participating health providers be not-for-profit: no stock offerings. This Improved Medicare for All would lower medical costs so much that doctors and hospitals would still be fully reimbursed within reason and wouldn't share with stockholders. Business need no longer cover employees, and individuals would pay a fraction of what their present plans cost, but get wall-to-wall coverage. The only losers would be medical profiteers like private health insurance plans, WHICH ARE THE PROBLEM and which we'd be better off without. They could continue to provide whatever insurance they can sell as long as it doesn't duplicate the Medicare for All coverage. Laid off insurance workers are promised preference for all the new Medicare jobs.

Commenter: Gordon Johnson
Prof. Singer does a good job of laying out the current forms of rationing but understates the effects of healthcare reform as miilion of the newly insured begin to hit the doctor's offices, hospitals and emergency rooms without any increase in the number of doctors and nurses to serve them.

Overlooked entirely are some of the root causes of hospital and emergency room closures: illegal aliens who are never asked for their green cards and are never sent back to their homelands when their conditions have been stabilized. Texas and California spend almost $3 billion a year on indigent care. If we spent that amount on immigration enforcement, we would enable more of our hospitals and emergency rooms to survive. Why is this obvious factor in the healthcare debate largely ignored?

Commenter: Kirsten Hinsdale
As someone who has worked in safety net health care systems for the last 25 years, I have carefully tracked the issues bearing on health care reform. Your analysis on last night's PBS NOW was the best I have seen. I have sent the URL for the Special Report to my colleagues at Boston Medical Center. The website coverage is also great.

Thank you for cutting through the morass of relevant issues to the core questions and giving viewers access to some of the brightest minds in health policy...

Commenter: Skippy Hau
I just watched the PBS special and appreciate the show but was disappointed that the issue of emergency rooms providing non-emergency care for non/uninsured public is being set up for failure like the no child left behind policy for schools.

Although I'm covered by insurance, when I had to be taken to the emergency room, I was given great medical care but when I look at the billing, it was overpriced or was I (my insurance coverage) paying for the other services being given to those who were unable to pay or had no insurance.....The special did not show the paperwork side of the bureacracy and the lag/delay in payments at various levels. I worry that the health care system will implode by continued legislative rambling and bureacratic inaction.

Commenter: George Morris
All healthcare reform proposals focus on secondary prevention and disease management. This can not reduce overall costs.

Please ask that CER healthcare funds are used to prove to the CBO that monies spent on Primary Prevention reduce overall healthcare costs. According to the Lewin Group we could save up to one trillion dollars per year if we could reduce preventable disease. No system of healthcare can be deficit neutral at 15 to 20 years out if we maintain the same disease rate. To change the disease rate we must focus on prevention not disease management. I would love to discuss this policy shift with any of your healthcare team. The Public Option can promote Prevention and reduce disease burden on our society.

Commenter: Marlene Hart
Health care is not a sofa, therefore, it should be sold like one. I feel single payer is the only way everyone will receive affordable access to health care.
But, since it is not what health insurance and drug companies want we will not get it. I feel the public option is the only way we will be able to make sure we have affordable-accessible health care in lieu of not getting single payer.

Commenter: Dr. Judi
Let me clarify- It is the primary care physician, the ones on the front lines seeing tons of patients, who get reimbursed at a ridiculously low rate. Specialists and surgeons on the other hand are paid handsomely for their procedures. This is another huge flaw of the current system

Commenter: Dr. Judi
Michael Tanner's arguments speak to the fact why we need single payer insurance not just a government option(which isn't going to happen anyway.) There's no artificiality about keeping administration costs low as Medicare already does. There would be no need to shift to insurance companies. While some hospitals may currently cost shift, it is actually physicians who are ripped off by the insurance companies/HMOs who are forced into agreements of reimbursement rates which are ridiculously low.

Forced into the government plan. What a specious argument. How many Americans, especially sick ones "love" their insurance company? They would in fact still be able to see their physician under this plan or single payer. Businesses shunting their employees into a public plan is again another argument for single payer. It's time to remove the responsibility of providing a health plan from employers to the public as a whole and at a much lower cost!

Commenter: Ray Stewart
Are these two statistic oblivious? Of course there will be rationing, just as there is in Great Britain.
Canada, France ETC. As of this minute, there are thousands in Great Britain waiting for hospital beds,
and thousands more waiting to get on the list for a hospital bed. Women suffering from osteoporosis cannot get prescription drugs. Canadians are flooding
American hospital facilities. Waits for various tests
run into months seriously affecting health conditions. If a government option is passed, will these two immediately resign from their existing plan
and enrollin the plan that they endorse? I bet not.
Hypocrites.

Commenter: Ray
Private plans ration already. Under the current system millions of Americans will be forced out of the insurance they have today. Businesses can move their employees into less expensive plans right now. In fact, it happens quite often. My wife is a benefits administrator. Every year insurance companies raise their premiums. She has seen increases as high as 30%. When the increase is too high, the business will switch plans. As insurance costs continue to rise, businesses will have less quality options that are affordable. They will face the choice of offering lower quality insurance or asking their employees to contribute more. A public option would provide a quality choice if private plans become unaffordable. It may also force private insurance companies to keep their premiums affordable.

Commenter: Sherry Hughes
Michael Tanner didn't even answer the question. As is typical these days, when asked a specific question, he and many others choose to ignore it and spew their demagoguery to detract from the real issue. Do they think we don't notice?

Commenter: LEE D. FOSS
You refer to this as a debate---???? both individuals give a biased endorsment for government controlled health care---this whole attempt to take over medical care is not about medical care at all---it is about power--socialism..there is no mention of effective tort reform which would effectively reduce present medical expenses--the only real benifactors from the proposed plan would be ambulance chasing--bottom feeding lawyers.