The Covert Rationing Blog

The Two Flavors of Covert Rationing

June 10th, 2007 by DrRich

As we learned in the previous post, the behaviors used to covertly ration healthcare in America are advanced by two different schools of thought. Once we are introduced to these two schools and become familiar with their philosophies, it will be easy for us to begin spotting covert rationing behavior when we encounter it, and to recognize who is behind it, what form it is likely to take, and what effect it will have on us.

School of Thought #1 - The Wonkonian School

This school of thought is the one most commonly espoused by governmental regulators, politicians, public health officials, political liberals, and policy mavens (hence, wonks).

Wonkonians believe that the root cause for all the problems in our healthcare system lies in human weaknesses (specifically, in too many greedy doctors using too much expensive technology). The fix for these problems therefore rests in setting public policy and promulgating governmental regulations to hold that greed in check. From a philosophical point of view Wonkonians believe in Original Sin, in the essential evil in man - if you give a fellow too much freedom, he’ll probably do something bad.

The Wonkonians’ point of view is amply supported by the undeniable fact that that the traditional health care system that most of us grew up with institutionalized the natural human greed of physicians. Under that system, the more technology doctors used, and the more medical procedures they performed, the more money they made. Indeed, it simply cannot be credibly denied that this system fostered profligacy, waste, and the over utilization of expensive resources.

According to the Wonkonian school, the greed inherent in our healthcare system is amply confirmed by the fact that millions of Americans have been shut out of the system (or at least, shut out of health insurance) altogether. Where is the cry of outrage from our “compassionate” physicians over the high number of uninsured? The greed is further reflected by a lack of quality in our present healthcare system - consider the embarrassingly high infant mortality rate in the U.S., and the lagging life-expectancy of Americans as compared to other developed countries. Again, where is the professional outrage? Clearly there is a fundamental problem with our healthcare system, a problem that stems from the misguided incentives and maladjusted motivations of healthcare practitioners and other profiteers.

Politicians and policymakers naturally gravitate toward this school of thought, since its basic premise is that the problem with healthcare results from misguided incentives coupled with human greed. This premise obviously places the solution squarely in the hands of policymakers, who can do the job with new, stricter regulations and more enforcement muscle.

School of Thought # 2 - The Gekkonian School

This school of thought is usually espoused by the insurance industry, healthcare executives, many physicians, and most proponents of a free-enterprise economy, including most political conservatives. DrRich has named it after one of his favorite characters, Gordon Gekko, the character in the movie Wall Street, whose chief operating philosophy was that greed is good.

Its basic premise is that the open marketplace generally offers the best solution to society’s problems. Philosophically speaking, Gekkonians believe in the essential goodness of man - give a fellow his freedom, and just watch the good things flow.

Gekkonians assert that the health care crisis stems directly from the fact that, while doctors may be good at practicing medicine (though, for all we know, maybe they’re not), they’re no businessmen. And health care is simply a business, like any other economic enterprise.

Leave it up to the doctors, and they’ll forever practice medicine the way they did in 1910 - hundreds of thousands of independent guildsmen, each running their own shop, duplicating expensive services, multiplying inefficiencies, and shutting out the competition. No wonder the health care system is such an inefficient, wasteful mess. Instead, the healthcare industry should be treated as a market, just like any other market, and not as some sacred, protected economic sphere.

Let those who know how to run a business run the business of healthcare, and let the doctors practice medicine (under the guidance, of course, of the fiscally adept). Bring the efficiencies of the for-profit, free enterprise system to the healthcare industry, and the healthcare crisis will take care of itself.

Wonkonians vs. Gekkonians - A comparison

At first glance, the Wonkonians and the Gekkonians would seem to have little in common. The Wonkonians believe that too much greed is the problem, so the healthcare crisis can only be solved by regulations to hold that greed in check. The Gekkonians, on the other hand, propose to allow market incentives (or, if you will, greed) to solve the healthcare crisis by reducing artificial constraints on the market (i.e., by reducing governmental regulations).

A closer look, however, reveals that these two schools of thought actually have very much in common; certainly enough to explain why Wonkonians and Gekkonians can often be seen forming alliances with one another in their efforts to “reform” the system.

First, both schools of thought are based firmly on the notion that the healthcare crisis is caused almost entirely by too much waste and fraud within the healthcare system. While one school tends to blame the waste and fraud on greed and the other on incompetence, the basic problem according to both schools is the inefficient use of resources. DrRich has described the fatal limitations of the “waste and fraud” hypothesis on his website - fundamentally this is the fiction that by increasing inefficiencies we can avoid the need to ration. It is a fatally flawed position. But still, it is attractive to suppose that enough waste exists in the system to make rationing unnecessary.

As a direct result of the “waste and fraud” hypothesis, both schools of thought are able to assert that the underlying problem is merely one of how the healthcare system is organized, that is, of who gets to call the shots and which philosophy gets to determine the “rules.” There is no argument by either group as to whether control should be centralized (clearly, it should). The battle is over which central authority should exert that control, and whether they should do so through regulatory means, or market-based means. In neither case is there any reason to question our underlying premises. There is no questioning, at least publicly, of the culture of no limits.

The Wonkonians and Gekkonians have one more common feature that deserves prominent mention. In each, the primary solution to the healthcare crisis requires limiting the capacity of doctors to behave as independent agents. In one case this is to be done by regulatory means in order to stifle physician greed; in the other it is to be done by the marketplace in order to eliminate physician inefficiency. But either way the primary goal, the number one priority, is to control physicians’ behavior. To the extent that controlling physicians’ behavior prevents them from being greedy or inefficient, that’s good. But to the extent that controlling their behavior prevents them from fulfilling their defining role as advocates for their patients, that’s bad. Very bad. (We’ll explicitly discuss the importance of the classic doctor-patient relationship, and why we can’t have it anymore under covert rationing, in a future post.)

Thusly does each school of thought provide a serviceable “cover” for activities that, if subconscious collusion were not the operational imperative, would quickly be seen for what they are - rationing activities. Indeed, understanding these two schools of thought allows us to comprehend the secret language of covert rationing. For rationing behavior is virtually always couched in terms of one school of thought or the other.

So far in the race to control our hearts and minds, neither school of thought has clearly predominated. In 1993 and 1994, the “heyday” of the Clintons‘ healthcare reform efforts, the Wonkonians were clearly in the driver’s seat. Then, when the Clinton plan went down to overwhelming defeat, the Gekkonians rapidly took the fore, and the short-lived hey-day of private managed care organizations flitted by. Now it would appear that the public has soured on healthcare run by the ostensible “free market,” and the Wonkonians are making a strong comeback. It isn’t likely that either school of thought will be vanquished any time soon.

But such a “horse race” scenario is a gross oversimplification. As we will see, many forms of covert rationing are supported by both schools of thought, and the battle has been characterized more by collusion than collision. In any case, for the doctors and patients struggling in the trenches, it doesn’t much matter which school of thought represents the paradigm of the day. For, whichever one is providing it “cover” at any given point in time, covert rationing in any guise renders the pursuit of healthcare exceedingly difficult, frustrating and dangerous.

Posted in An Introduction to Covert Rationing, Gekkonian Rationing, Wonkonian Rationing

One Response to “The Two Flavors of Covert Rationing”

1. The Covert Rationing Blog » Blog Archive » Weep Not for UnitedHealth Group wrote on 09/6/07 at 9:21 am :

   […] hope so. For, on the grand scheme of things, this new development is just the latest battle in the ongoing struggle between Wonkonians and Gekkonians. Here, the Wonkonian regulators are attempting to take a giant step toward their ultimate goal of […]

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