Introduction to Covert Rationing

Podcast:

The purpose behind DrRich’s Covert Rationing Blog is to explain healthcare rationing in America – why rationing is unavoidable, why we’re doing it covertly, and why covert rationing produces the most destructive kind of healthcare system we could ever imagine.

Many definitions for “healthcare rationing” have been advanced, and most of them talk blandly about such things as the allocation of scarce resources, or the fair distribution of available benefits, or goods, or commodities. DrRich objects to such definitions on the grounds that they are misleadingly soothing. There’s nothing pretty about healthcare rationing. Rationing is bad. And if we’ve got to do it, we ought to face up to exactly what that implies. Facing the facts might keep us more honest.

So, here’s the definition that DrRich likes:

To ration healthcare is to intentionally withhold at least some useful medical services from at least some of the people who would benefit from them.

This definition has the virtue of being straightforward. It does not try to pass the onus of rationing onto those “scarce resources” themselves, or to hide what’s actually going on behind comforting euphemisms.  This definition should make it more difficult for us to dance around the real issue, which is: Healthcare rationing is bad. It will hurt at least some people at least a little bit, and quite possibly it will hurt a lot of people quite a bit.

So if we decide we have no choice but to ration, then we should feel obligated to do it in the least harmful way possible.

Having defined healthcare rationing in this way, it is possible to lay out the entire foundation of the Covert Rationing Blog with a simple four-point thesis.

Point #1: Healthcare rationing is a fiscal imperative. Rationing is fundamentally unavoidable, and therefore, we are not avoiding it.

There are two ways of explaining why healthcare rationing is unavoidable, the short way and the long way. You can read the long way if you wish in DrRich’s book, or in the parent website of this blog. But here, we’ll stick to the short version.

In any advanced society, where a centralized agency of one species or another creates a pool of money from which most of the society’s healthcare bills are to be paid, whether that pool of money is controlled by the government, or by private insurance companies, or by some combination of these, then even if that centralized agency is very large, very powerful, and very coercive, there will always be limits on how much money can be placed into the pool. On the other hand, the amount of money that could conceivably be spent to purchase all the available healthcare for every individual in the population who might benefit from it is essentially limitless.

This limited supply, and limitless demand, means that somebody, somewhere, will not receive all the available healthcare that would be potentially useful to them. So rationing is occurring. Q.E.D.

Point #2: We’re Americans, and Americans don’t ration. So the unavoidable rationing must be, and is being, done covertly.

An endearing trait of Americans, endearing to us Americans at least, is our limitless optimism, our undying belief that anything good that we can imagine can, and will, actually be accomplished. This refusal to recognize limits is responsible for much of the creativity, inventiveness, and productivity that has come from American society. And it has led to much good in the world, resulting, for instance, in most of the remarkable advances in healthcare we’ve seen over the past half-century.

The American culture of no limits, however, can be carried to counterproductive extremes. And that is what has happened with regard to healthcare.

Our “no limits” attitude about healthcare is typically American. It goes like this:

In America we have, and will continue to have, the best healthcare in the world – the best doctors, the best hospitals, and the best technology. Since one cannot place a price on a human life, anything that can be done for a sick person must be done, as long as there is some small hope of even a tiny benefit. Every disease is potentially curable, and as a matter of policy we will strive to learn how to cure very disease that exists (and when we run out of diseases to cure, we’ll invent new ones). Indeed, death itself is merely a manifestation of insufficient technology.

In summary, where healthcare is conderned, there are, and can be, no limits.

We can see the problem right away. While we have inherent spending limitations that unavoidably require healthcare rationing, we find that there can be no limits, and therefore, no rationing. Indeed, there can be no discussion of rationing, except to bitterly condemn the very idea. Any political leader or policymaker who would seriously suggest the idea of healthcare rationing would run squarely into this deeply ingrained culture of no limits, and would immediately become toast.

So, these two basic imperatives shaping our healthcare system – the unavoidable need to ration that will always accompany publicly-funded healthcare, and the culture of no limits – are, in their essence, completely incompatible with one another. Given our deep-seated need to simultaneously cling to both of these incompatible imperatives, our only option is to do the unavoidable rationing in a way that maintains the fiction that no rationing is necessary, in a way that allows us to ration while declaring that there are no limits, and to deny that any rationing is occurring at all. We can ration secretly. We can ration deceptively. We can ration covertly.

And that is what we are doing.

Point #3: Covert rationing is inherently and extravagantly destructive, not only to patients and their doctors, and not only to the healthcare system, but also to our basic American social contract.

Most of the commentaries that appear on the Covert Rationing Blog directly address Point #3. So DrRich will not elaborate on this point here, except to make two brief assertions, whose truth, he believes, should become quickly apparent to anyone reading more than a handful of the posts appearing here.

First, while there are plenty of problems with the American healthcare system, the truly intractable ones are intractable largely because of our need to ration covertly. As long as we continue rationing our healthcare covertly, these problems will persist.

Second, by its very nature covert healthcare rationing is a deeply ironic construction. The whole purpose of rationing is to reduce spending on healthcare, and to control costs. But covert rationing (ironically) always increases expenditures. If we could ration healthcare openly, then it is possible that we could arrange, or at least try to arrange, the rationing in such a way to optimize the efficiency, effectiveness and equity within our healthcare system.

But rationing covertly fundamentally means rationing in whatever way you can get away with. So, in order to hide the rationing, it imperative to obfuscate, misdirect, complicate, juke, jive, shimmy and shake and do whatever else you must to to convince everyone – often including yourself – that whatever it is you’re doing, it’s not rationing. That is, you’ve got to create an environment of complexity and opacity in which you can get away with it.

As a direct result of this simple truth, simplicity, transparency and efficiency are lethal to a system based on covert rationing, and thus, are systematically rooted out. Covert rationing absolutely requires opaque processes and procedures, superfluous complexity, bizarre incentives, Byzantine regulations which are arbitrarily enforced or ignored in various times and places, and the diversion of healthcare dollars to a complex host of non-healthcare ends, such as commissions, study groups, various czars of this and that, ever-expanding layers of government bureaucracies, and the establishment of other massive bureaucracies within the healthcare system whose purpose is to defend against or manipulate those government bureaucracies.  Covert rationing, by its very nature, demands and creates more waste within our healthcare system, and therefore costs us far more money than it can ever save us.

Covert healthcare rationing is, in this way, a deeply ironic construction.

Point #4: As painful as it may be to contemplate, any reform plan that hopes to provide fair, effective, and efficient healthcare through public funds, and hopes to keep the necessary rationing to a bare minimum, and hopes to preserve the long-term feasibility of a vibrant, and reasonably equitable society, is going to have to acknowledge the unavoidability of rationing, and to devise a completely transparent and open system for doing it.

In general, DrRich will not be addressing detailed solutions to our healthcare crisis on the Covert Rationing Blog, but he does wish to point out that he has, in fact, addressed such solutions in substantial detail elsewhere – in substantially more detail, he submits, than is generally provided by the people who we pay to do this work.

If you would like to find out more about DrRich’s proposed solutions to our healthcare problems, you can look in his book, or on the parent website of this blog.

A Personal Note

Before closing this introduction to covert rationing, DrRich would like to add a personal note. In writing the Covert Rationing Blog, DrRich has affected a certain persona that, he humbly submits, is quite unlike his actual self. DrRich of the blogosphere is a bit haughty, perhaps even with a bloated sense of self-worth – insisting, for instance, on referring to himself in the third person. He intentionally employs complex sentence structures, and archaic verbiage, and, in describing the American healthcare system, he often resorts to exaggeration, satire, sarcasm, and above all, irony.

DrRich does all this, first and foremost, because he finds it amusing. He enjoys writing in this manner, especially after having spent several decades writing large quantities of stuff in the stereotypical, dry academic style insisted upon by editors of medical journals and textbooks. Nowadays he enjoys making some of his readers smile. He also derives a certain, perhaps somewhat perverse pleasure in scandalizing some other of his readers, mainly, those who insist on interpreting the written word entirely at face value, and so who will believe, for instance, that DrRich actually likes the fact that 47 million Americans have no health insurance, that he really believes that what our healthcare system needs most is even more waste and inefficiency, and that we ought to take every opportunity to dehumanize fat people.  The indignant e-mails he receives as the result of such literal-mindedness – each one of which is a treasure – makes DrRich feel positively Jonathan Swiftian.

But perhaps more relevantly, the arms-length, stand-offish effect of referring to oneself in the third person, and the liberal employment of devices such as circumlocution, sleight-of-hand, faux sincerity, and all manner of irony, are, DrRich hopes, useful and uniquely illustrative in a blog which, after all, purports to illuminate a healthcare system that is behaving in exactly the same way.

DrRich thinks it is important for others to understand covert rationing in the same way he does, and he is not above recruiting every trick he knows in his attempt to accomplish this goal. For as long as we insist on rationing covertly, our healthcare system will remain hopelessly mired in waste, inefficiency, inequity and destructiveness. On the other hand, we can fix this if enough of us understand what we are facing. With the Covert Rationing Blog, DrRich hopes to entice at least a few other people to have a look behind that curtain.