I know it’s coming; I can feel it in my aging bones. And since I don’t want to be caught unprepared when the rationing of my medical care formally arrives, I think about it just enough — hoping to become psychologically immunized. Of course, for many in the U.S. without health insurance, their rationing arrived a long time ago; no preparation was possible. But for most of us who still enjoy some level of medical coverage and have not gone bankrupt because of it, we still can’t imagine anything less than what we have. In fact, not only do we want more medical care, we want it better and faster. As a result of this fantasy, we are woefully unprepared for what is coming our way.
Why am I obsessing about this? It’s because we simply can’t give health insurance coverage and benefits to all 300 million U.S. citizens and reduce our medical costs at the same time. The seductive words mouthed by legislators and providers about improving care efficiencies, computerizing medical records, and managing chronic diseases are, so far, without cost-saving teeth. And reducing our collective medical costs is impossible because our society just won’t allow it. We want to retain our individual freedom to behave in any unhealthy way we choose, whether living as a couch potato, having an unquenchable thirst for alcohol and smoking, or texting while pretending to be a NASCAR driver on Hogan Road. This entitles us to say, “You aren’t going to force me to behave any differently, thank you. But I will appreciate your financial support for medical care if things go badly for me in the future.” Without healthy behaviors being mandated, our medical care, and the concurrent costs, will continue to increase with or without health insurance coverage. Explicit rationing will be the only way the government can put the brakes on health care costs.
I tried to ration some of my own care, which was harder than I thought. I recently had a nasty laceration that normally would have prompted a trip to the local emergency room for several stitches. But having at least some medical background, I took a risk, albeit a low one, to stay home and tend to it myself. It turned out just fine, but it could have easily — and expensively — gone in another direction.
Self-managing little wounds is not where rationing will be most effective, though. It will be in the big, expensive, and relatively low-probability-of-cure medical treatments that we now receive, such as end-stage cancers or heart disease. And the decisions won’t be made by a secret panel of hooded executioners, which is contrary to what some slightly paranoid folks might suggest (I am confident our society would throw any scoundrel out of office who might propose such an approach).
Rather, we are more likely to see a method of ethical rationing other countries have implemented. Since no one in government will want the responsibility of telling an individual in an open and transparent way that they cannot have a specific treatment because of costs, they will likely say instead, “You can have this treatment, but it won’t be for six months or a year because there is a waiting list. During that time, if sicker, go to your local emergency room and you will get the care you need.” It seems to me to be the most fair of all other known systems.
I am eight years away from becoming Medicare eligible, but I expect to see a reduction in those benefits by the time I access it. I watched President Obama give his speech last month about health care reform and Medicare, and he was wrong to infer that the only treatments at risk for nonsupport will be those that do not add value to our overall health. Seniors will not be exempt from rationing, since they — and soon to be me — demand more care as they age.
Here is what I am psychologically preparing myself for: Everyone in the U.S. will finally be insured; the costs of medical care will inevitably go up; a formal rationing of some Medicare benefits when I reach age 65; the government determining an annual health care budget and, like other states and countries, disciplining itself not to exceed it; a rationing method driven by wait-times, not by a panel of fascist treatment-deniers accountable only to themselves.
I am as uncomfortable as anyone about the idea of rationing our medical care, but that train is on the track already and cannot be stopped. The only issues are these: What will it take for us to acquiesce to the idea we can no longer have everything we want when we want it, and what method of rationing is most fair and ethical for us to employ.
Michael D. Skinner of Surry was president of a community hospital in Massachusetts. He now teaches at Husson University.