1/ Rationing is a reality even in countries where it is officially denied. The reason is public debt. Not rationing increases public debt. consequently when a state borrow to pay for healthcare or for other social advantages it is obviously by rationing the next generation. This next generation will pay for the interests and the debt itself. It could be the case in US where a complete coverage of the entire population at the present cost will provoke a huge public deficit and an abbyssal debt
2/ Medical treatment efficiency is largely overestimated for multiple reasons. Economic assymetry and other factors keep medical evaluation in the hands ot those who practice or sell goods and services related to illness or intended to cure it . Despite that, the proofs of the efficiency of healthcare spending on longevity and/or quality of life are not strong. Worst, exercising, dieting, environmental improvment, education and socioprofessionnal status are stronger determinants of longevity and quality of life. Their modifications have a tremendous effect on health whatever the way. Consequently rationing could be less mandatory if basic health insurance (which is paid by taxes for those who cannot afford it) reimburses only the core of medical treatments and procedures for severe illnesses. The list may be controversial but it is clear that presently a vast extent of treatments and procedures are inefficient, without any effect or dangerous; so health expenditure should be devoted to severe situations. According to experts of the field sevre situations either acute or chronic encounter for 2/3 only of the total of money. Eventually the 2/3 of the amount will be spent on seriously evaluated treatments in these severe illnesses for all the citizens. For other expenditures patients will take the money out of the pocket or will not decide to buy, a form of harmless rationing.
3/ Rationing is good for health and bad for illness. In our societies and especially in US regarding the high cost of the healthcare system, such a high illness related expenditure has an economic and psychologic crowding effect on individual responsability. It has be proven that prevention is efficient if it is based on personal responsability. It is costly and of doubtful efficiency if based on more medical screening and imaging procedures and enventually more surgery or drugs. By spending and wasting at least 30% of all our resources in the treatment of illnesses, we crowd out the resources for prevention at both the individual and collective levels. It is of paramount importance to stress that taxpayer health insurance will have the same effect if generalised to all goods and services provided by the healthcare industry, a model that Medicare in US or Sécurité Sociale in France, exemplifies perfectly.
So rationing is the consequence of the limited amount of available resources and the limited efficiency of present medicine. When the FDA disgard some treatment it is rationing for safety. Rationing is also mandatory in the search of efficient treatments. Unefficient ones should be stopped or allowed in clinical trials at the expense of the promoter or purchased by indivduals out of the pocket or by a private non deductible insurance.
Who should ration? That is the question.
The first factor is external, it is creation of worth; this economic factor should be emphasized. As a national coverage is decided with taxpayers who subsidy the premium for poor people a weak growth of the GDP will enforce the state to borrow. then it is obvious that without economic growth health insurance for all, even a basic one, is in danger.
The second is a regulatory agency. Allowing patients to consume all the medical goods and services provided by the healthcare system freely is dreadful for the state budget. Allowing practitioners to prescribe and garantee the reimbursment of all good ansd services provided by the healthcare system leads to the same exit.
In UK it is NICE. In france HAS. It is of paramount importance that the agency should be kept away from conflicts of interest. It is possible and one can suggests that a dual power (a government agency and a consumer commission) could do the job. Although one can predict that this job will be very difficult and decisions controversial because economic stakes are huge.
In conclusion, instead of ignoring rationing we should address it boldly and smartly because it is a natural and vital issue in the debate on basic health insurance for all.
http://www.nytimes.com/2009/
http://www.ft.com/cms/s/0/f6ad0b18-8b59-11de-9f50-00144feabdc0.html?nclick_check=1