Posted by: Jeff | September 25, 2009

The Moral Case for Rationing

Here’s an interesting bit from an interview Ezra Klein did with Kent Conrad, one of the moderate Democrats in the Senate.

Different parts of our system fit different models. Part fits the Beveridge model. Part fits the Bismarck model, where employers and employees contribute and it’s private doctors and hospitals. And other parts are national health insurance, which is Canada, and that’s Medicare. For our senior citizens, we have adopted the model that is closest to the Canadian model. But there are serious issues with that model if it spreads society-wide in terms of waiting times. I don’t think that fits American culture.

Matt Yglesias promptly pounced on this, pointing out that if we expanded Medicare to all, but maintained our current levels of per capita Medicare spending, we wouldn’t have waiting lines. True, but if we were to expand the Medicare model to the whole country, I don’t think there’s any way we could maintain those spending levels. Spending levels for Medicare are killing us as they are. So in a sense, Conrad is right. If we went that route we’d get more waiting lines.

But there’s a deeper moral point to be made here. In Canada, 27 percent of the population has to deal with waiting lines. But only 6 percent of the population goes without care entirely because they can’t afford it. Meanwhile in America, the numbers are almost perfectly reversed. 22 percent to 26 percent of Americans go without treatment entirely because of costs, while only 5 percent have dealt with waiting lines.

Waiting lines and going without treatment entirely are all parts of the downside of rationing health care. And every society, including America, already rations health care. We have to because health care, just like anything else, is not a limitless resource. It’s just that here in America, we don’t think we do because of how we’ve distributed the rationing. We use the free market to hide the rationing from ourselves.

Canadians make sure just about everybody has access to decent health care, and the trade-off is that everyone in Canada has to deal with a certain amount of waiting lines. In America, we’ve eliminated waiting lines by effectively denying decent health care to a fourth of our population. We take all the upsides of our rationing system – the high quality, the short waits – and give them to the upper classes and the elderly. Meanwhile, we take all the downsides of our rationing system – basically, going without care – and dump them on the lower classes and the poor.

So it’s no wonder seniors and economically fortunate Americans, who are also the groups most likely to be engaged in the health care debate, are freaking out about rationing and waiting lines. They’ve never had to deal with those problems, because our system protects them from having to shoulder those problems. (Unless they happen to be among the unlucky ones with a pre-existing condition or some such.) At the risk of being overly dramatic, their comfort is quite literally being bought in the blood and suffering of their less fortunate fellow citizens. Citizens who, by and large, have no voice in the current debate precisely because they’re poor or working class.

Which makes Sen. Conrad’s take about “American culture” – and the need to create a system which adheres to that culture – exceedingly weird. What if our current cultural preferences are wrong? What if what our culture wants is, to put it bluntly, immoral? Because it looks to me like that’s precisely what’s going on, given Conrad’s description. One could just as easily say what needs to happen is for our culture to change to embrace the new system, rather than for the new system to change to embrace the culture.


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