This week the Insights blog will be focusing on health care issues.
It is amazing how a single word can distort a debate. Take the word ‘rationing’. What does that mean to you? To me, it conjures up a world of little cardboard booklets, which record whether or not you have been allocated your personal portion of eggs, butter, or flour. A world in which it makes sense to ask whether or not someone has had his or her ration.
In the US debate on health care reform, conservatives warned US citizens that, aside from the horrors of state control, universal health-care would inevitably lead to UK style health rationing. The debate about rationing largely focused on the question of whether it is a lesser evil than a system which, despite pouring much more money into health care per person than any other in the world, still left perhaps as many as 50 million people without health insurance.
I was completely bemused by this debate, and couldn’t understand why ‘progressives’ were prepared to let it be structured this way. For consider. Do we have rationing in the UK or elsewhere in Europe? Where do you keep your ration card? Has your NHS doctor ever refused to see you because you had used up your allocation of appointments? Has a hospital told you that you had already spent your share of nights on the ward?
What we have in England and Wales is the National Institute of Health and Clinical Excellence (NICE) with the job of deciding whether or not a new treatment or intervention is cost-effective. Sometimes, to the fury of patient groups and pharmaceutical companies, it decides that a drug is not worth the price asked for it, and recommends that it is not ‘refunded’ by the National Health Service.
Now, this is bound to cause dispute, and makes excellent news stories. It is easy to find someone who believes that their condition would be massively improved if an excluded drug was made available, and that NICE heartlessly puts a price on life. And indeed, we can argue that NICE may have erred in particular cases, or, more generally goes about its decision-making the wrong way. But it is hard to argue that considerations of cost are never relevant. If a drug cost ten thousand pounds and extended a life by an hour, it would be a difficult to argue that it should be made available at public expense. Sometimes we must put ‘a price on life’, somehow or other.
It is true, then, that the NHS has cost-effectiveness tests for pharmaceuticals and some other interventions. It also has a type of ‘demand suppressant’ in the form, often, of long waiting times to see consultants and for specialized services. What it doesn’t have is rationing, in what seems to me the ordinary sense of the word.
Oddly, if you want to see examples of health care rationing in practice, one good place to look is the USA. Even the most generous health insurance policy has limits on how much a patient can claim. Everyone in the US has a story. Here is one: a distinguished university professor, with the best insurance package available to him, was involved in a serious accident, and for a while was in a critical condition, in intensive care. His insurance policy was capped at two million dollars. I spoke to his wife six weeks after the accident, and the bills had already reached one million. They simply had no idea what they would do if and when they hit their limit. Or, as we might say, used up their ration.
In the UK there is control on the price that will be paid for particular treatments. If a treatment is too expensive, given its benefits, it will not be made available on the NHS (although often it will be available for private purchase). In the US insurance system, there is no central control on the general availability of treatments. But how much will be spent on each person depends on their insurance policy and personal resources. I’d like to describe this as a system in which there is rationing in the US and cost control in the UK. A decent set of health reforms in the US, as we are just beginning to see, would end rationing, and bring in cost control. But I’m not expecting to be invited by the US medical establishment to come and speak on the topic.
Justice and access to health care Stanford Encyclopedia of Philosophy