What I haven’t seen . . is a study of how the system will make the hardest decisions about health care: who gets care and who doesn’t, especially at the beginning and ending of life, where a large portion of our health care dollars are spent?

Health Care – Is Anyone Asking the Hardest Question?, Jeffrey Clayton, The BNA Pension & Benefits Blog (May 16, 2008)

I recently observed that a post on Lawrence Solum’s Legal Theory Blog noted an essay by Lee Anne Fennell (University of Chicago Law School) that presents a helpful framework for evaluating the policies underlying allocation of entitlements. The essay takes as its assumption what should be a self-evident premise – namely, that when allocating resources, one must begin with the acknowledgment that resources are finite.

Jeffrey Clayton makes this point in a well written comment on the BNA Pension & Benefits Blog. So far the health care reform debate has been riveted on free access to health care. As Jeffrey notes, however, in other health care systems, rationing of care is often an implicit assumption.

He notes:

In other systems, much of the care we hold so dear is not available to the very young or the very old and sometimes in the middle. Some European cultures take a much more practical view of the end of life and focus more on dying in comfort rather than fighting a very costly, but losing battle using the most sophisticated (and usually expensive) methods to prolong life.

This point need not carry a normative aspect. It should, however, encourage an attempt at objective evaluation of the limitations of health care systems that are compared to our own. So long as health care cost increases are uncritically accepted we cannot make substantial improvements in our health care system regardless of how we choose to finance health care.

Jeffrey concludes that:

. . . without a mechanism to control what care is available and to whom and at what time, costs will continue to be a problem. We have more technology than we can afford. In national health care systems care is rationed by either long waits or guidelines that restrict access. There is no political will in America to suggest that we really can’t afford to give everyone everything they want when they want it. As a result, no one asks the hard question, who is going to decide what care and when?

When we have so little transparency in costs that the federal courts must serve as battleground for state laws requiring disclosure of rebates, kickbacks and soft dollar compensation of PBM’s, it is highly unlikely that any change in health care funding presently under discussion by the candidates will lead to realistic solutions to the deficiencies in delivery of health care services. Under any set of assumptions, however, limited resources will of necessity lead to rationing of health care as in the case of any other resource.