For many years the Lung Association in conjunction with the Ontario Thoracic Society have featured debates as part of the format of their conferences. These debates are intended to be a serious and provocative look at a significant topic but presented in a way that is engaging and at least a little playful. I was involved in one of these debates over the weekend on the topic of “rationing” in universal health care. As it turns out I was charged with defending the view that “rationing” ought not to be a part of universal health care. The actual content of the debate – and the cut and thrust of the debate format are not really the focus of this post – but the underlying issues that rose to the surface are worth discussion.
There are some things that are clear. Demand for health care services is unlimited – and supply of those services – or the resources to meet the demand is limited. So there has to be some way of matching the supply with the demand, some way of allocating the scarce resource. On the rationing side of the debate it was argued that, from an economist’s perspective, anything other than a free market entails rationing (by definition) so, as we do not have a free market in health services there must be rationing. Unfortunately the debate got rather stalled at this point – it became a discussion of what the word or concept “rationing” might mean. I think it is quite possible to argue in ordinary language that “rationing” means something like equal shares or allotments but I don’t think this is the real issue – the issue that actually warrants discussion is what do we do when our unlimited demand for health care services outstrips our capacity to meet that demand?
There are several special features of health care (or perhaps more properly we should call it “sickness care”) that warrant our particular attention. In the first place one does not need “sickness care” until or unless one is sick. That is, “sickness care” responds to a need, perceived or actual. On our model of sickness care we are not required to allocate the resource to those who are not sick, to those who do not need it. Next, health or sickness care services can only be delivered by professionals with a highly regulated form of training. And finally, on our model of health care, those services are, more or less, only paid for by a single payer – the government.
Now we can ask the interesting, and difficult, questions. Who decides what health or sickness care services should be paid for by the government? And what sort of a decision is this? I think these questions are interesting and difficult because they require a wide range of different types of expertise to answer – and they do not fall cleanly into the decision-making jurisdiction of any neatly defined entity. So, the decision about what health needs should be funded is not simply a “medical” decision to be made by medical practitioners. Nor is it simply an economic decision to be made by health care economists, nor is it just a political decision to be made at the ballot box. Rather it is a question – or series of questions about what we, as a community, value – and how our values in health care stack up against other community values, like education, or security, or roads, or art – or indeed the ability of each of us to spend our own money as we wish. Let’s make this concrete – do we as a community wish to fund keeping a person’s body alive when there is no reasonable prospect of a meaningful recovery? Do we spend tens of thousands of dollars on a cancer drug that may extend life by a couple of months? What other things are we prepared to forego, including funding for prevention in health care, in order to make those expenditures? Who should make those types of decisions – and what should count as a reason one way or the other?
But there are more questions that are worth asking. What do we, should we, say about those health care services we, as a community, decide should not be funded? If we choose not to fund the cancer drug that may only bring a couple months of extended life, should we allow individuals to spend their own resources as they wish and purchase health or sickness care that the community is not prepared to fund?
I think these are the difficult choices that we currently face in health care. I think this discussion can easily get derailed by a focus on the concept of “rationing” which can obscure the real questions and distract us from the difficult task at hand. What do you think?