The reality of rationing

Opponents of the main Democratic proposals for healthcare reform warn that consumers would be stopped from getting the care they need when they need it. President Obama's plan is "rationing," one political strategist blogged. It's an unrealistic criticism, yet policymakers shouldn't sugarcoat reality: Rationing is part of the healthcare system today, as it will be under any overhaul fashioned by Washington. That's no argument for sticking with the current approach, however. Without significant improvements in the way healthcare is delivered and paid for, the escalating costs will cut off more people from the care they need.

The current system rations care by income, an approach that leaves millions of people who have limited resources and no insurance with few options beyond free clinics and emergency rooms. This situation is acceptable to many (especially the well-insured) because it doesn't involve the government deciding which treatments doctors can provide or which procedures insurance companies can pay for. Instead, services are available to anyone who can afford them, much as food and shelter are, with the safety net of Medicaid to support the poorest Americans.

Still, there is some government rationing. Washington and the states limit eligibility for Medicaid to the indigent, excluding many of the working poor who aren't covered by their employers. And the reimbursement rates for government insurance plans -- Medicaid in particular -- are set so low, a diminishing number of doctors and hospitals participate. Those patients have to travel farther and wait longer for care.

Critics of the healthcare reform bills now moving through Congress insist that more extensive rationing would result if Congress created a Medicare-style, government-run insurance plan to compete with private insurers. Another likely source of rationing, they say, would be a government-led effort to compare the effectiveness of different treatments. They point to Britain's National Institute for Health Clinical Excellence, which has denied funding for selected drugs, surgeries and diagnostic treatments that didn't meet its threshold for value.