Can We Say No?: The Challenge of Rationing Health Care

Excellent analysis of the health care mess. However, like almost all other such books, it stops short of a solution. For a thought provoking formulation of a solution that provides better health care at lower cost by clearly defining what the health care system is supposed to be accompishing, and squeezing the fat out of the system, see "You Bet Your Life: The Zero Sum Health Care Game", available at [email protected].

I just heard one of the authors interviewed on NPR. Henry Aaron states in the opening that if health care costs continue to rise, they will move from 16% of the GDP in 2005 to over 33% by around 2030. He includes the caveat "that is a big if" yet the entire discussion assumes this is really inevitable. Yet when one consider that technology is accelerating as pointed out by engineers Bill Joy, Ray Kurzweil, and others, medical technology will significantly transform health care over the next 25 years. Rather than costs increasing as a percentage of GDP, it is perfectly realistic to assume costs will instead decrease over the longer run. We saw this trend with computers where Americans spent more and more per GDP on computers as computers and more software became available to more people. Yet at some point this trend began to reverse as computers became much cheaper even as they became far more powerful. We will see health care costs *decrease* over time and the driving force - accelerating technology - should not be dismissed. The book makes sense over the shorter run and should be read with that timeframe in mind.

This is a topic that should get more attention than it does. Increased rationing of health care is coming, no matter how much we want to wish it away. Aaron and Schwartz deserve credit adding to the, so far limited, discussion on the topic. The book is largely a comparison of the provision of certain services in the United States and Britain. The British National Health Service was established after World War II and it generally holds down costs by establishing global budgets and requiring providers to operate within them. This method is likened to managed care by some. The British system has much lower use of services such as dialysis and fewer intensive care beds, even after adjusting for population differences. Given lower capacity in some areas, the British have to been much choosier about who receives care in these areas. The British system of rationing was largely unregulated, in the sense there was not often a uniform criteria for choosing one patient over another. Rather providers were obliged to simply make do within their budgets and this helped create a "culture" of care provision that differs from the culture in the United States. Beginning in the 1980s, technological advancements and increased expenditures in some of the most heavily rationed areas, such as dialysis, greatly increased the capacity to provide care although rates of treatment are still far lower than in the U.S. The authors suggest it might be wise for the U.S. to copy some aspects of the British system to help hold down costs. However, they acknowledge there are some significant differences, such as an American legal system that gives deference to demands for care.