I think right now we have a system that rations health care. It denies it to the 47 or so million people who don't have insurance; it restricts health care to the people who don't have enough insurance; it denies it those people who get sick or have a preexisting condition; and it limits it those people who can't afford the limits and co-pays. The real worry, however, for Michael Gerson, is whether (1) somehow people can afford abortions–a procedure which is legal; (2) whether there will be rationing. To be fair, he admits–sort of–that there is rationing. Rationing done by insurance companies.
The same is likely to be true of end-of-life issues. Talk of "death panels" is the parody of the debate — hyperbolic and self-defeating. But a discussion about the prospect of rationing in a public health system is not only permissible but unavoidable. Every nation that has promised comprehensive, low-cost health coverage for all citizens has faced a similar dilemma. Eventually it is not enough to increase public spending or to reduce waste. More direct forms of cost control become an overwhelming priority. And because health expenditures are weighted toward the end of life, the rationing of health care often concerns older people most directly.
Keith Hennessey, former director of the National Economic Council, puts the dilemma simply: "Resources are constrained, and so someone has to make the cost-benefit decision, either by creating a rule or making decisions on a case-by-case basis. Many of those decisions are now made by insurers and employers. The House and Senate bills would move some of those decisions into the government. Changing the locus of the decision does not relax the resource constraint. It just changes who has power and control."
So he admits it. It would be nice at this point to talk about the effectiveness or the fairness of the current program of rationing. But no.
Because no one likes to ration directly, nations such as Britain and Germany employ "comparative effectiveness research" to lend an air of science to the process of cost constraint. Are "quality-adjusted life years" worth the public expense of a new drug or technology?
This type of question is unavoidable when resources are scarce and planners take charge. They seek to rationalize the inefficient medical decisions of families, doctors and insurance companies. But the very process of imposing a rational structure gives government extraordinary power. And the approach taken by planners is, by necessity, utilitarian — considering the greatest good for the greatest number. Decisions cannot be made on a human scale.
On the rough ethical edges of life and death, American health care has adopted messy, inefficient, decentralized compromises that a nationalized system is likely to overturn. Particularly if that system is imposed on a "go-it-alone" Democratic strategy, the divisiveness is only beginning.
The weird thing about this argument is that the insurance company is now the victim–not the perpetrator–of rationing. On the current system, they're the ones who decide who gets covered and who doesn't. The basis of their choice is a very simple and efficient one: (1) who is not sick; (2) who can pay. The very idea of alternative system, one which bases decisions on care on some kind of principle (and no for Pete's sake it doesn't have to be by necessity "utilitarian") to Gerson raises the specter of Soylent Green. It's people folks, it's PEOPLE.