I Want My Slice of the Pie: Rationing of Health Care in the United States, An Inevitable Consequence of Increasing Health Care Costs

The bottom line up front (BLUF): “Following the passage of the Affordable Care Act (ACA), much of the national discussion was focused on expansion of coverage and value in health care, but new concerns about rationing of care are emerging.” And who do you think this is going to affect? That’s right, the have not’s. In a recent blog, I wrote about a two tier healthcare system developing with one for the haves(who have resources etc) and the have not’s (who lack such resources). So now another ethical problem emerging with the rationing of care. It’s likely not the private healthcare plans, nor the Cadillac plans that will ration, but those on the government plans of Medicare and Medicaid. I would hate to think that it would affect both Veteran’s and Military Retiree plans, but those are government run, so nothing is off the table. Bauchner (2019) writes: “The cost of health care continues to increase, now approaching 18%of the US gross domestic product. Health care expenditures consume approximately 30% of many state budgets.”Then projected rates of increase exceed the rates of inflation. Where’s the money going to come from? You can only tax people so much. Cuts. That’s right, cut’s will be needed. But what and who’s plans will be cut leading to a cut in care? You guessed it, again not the private and Cadillac plans. The have not’s lose again. 

For the United States to prosper in the 21st century, controlling health care costs is critical—indeed, it is the single most important challenge facing health care. Greater rationing of care is inevitable if health care costs continue to increase. Controlling health care costs is the only way to ensure appropriate investment in other areas, such as education, the environment, and infrastructure, and to provide a more equitable, just, and fair distribution of the remarkable health care advances that have been achieved with even more on the horizon.

            I surmise too that conditions such as obesity, hypertension, diabetes, addiction etc, which are modifiable with changes in lifestyle, will be conditions that care to will be cut also. What’s to stop the insurance plans from discriminating against these conditions on the belief that individual’s own choices lead to the condition, so they should pay for it themselves. After all, the cuts need to come from somewhere right? While some risk factors in these conditions are not modifiable and anyone one can be subject to developing them, often it’s the most vulnerable in our society with more risk factors more often facing the greatest healthcare need (the have not’s). Isn’t the Hippocratic Oath still relevant today? Having recently just graduated medical school and taking the Oath, maybe I’m jaded into believing that it is relevant in the equity of care provided regardless of societal class or socioeconomic status. However in 2019, it seems pretty easy to discriminate against the poor, the obese, the addicted, the afflicted etc. The article closes with: 

It has been said many times that in the richest country in the world, inwhich many of the greatest scientific and medical advances are developed, it is a blight on the US soul that each of its residents does not fully benefit from available health care.

The two headed dragon strikes again!

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Robert Duprey MD

Robert P. Duprey Jr studied medicine as a 2nd career medical student who went to medical school in his 40’s after honorable discharge and ‘retirement’ from 25 years in the US Military (USCG & US Army). He was a registered nurse (RN) with specialty training as a psychiatric RN in the US Army for 15 years. During this time he also became a Master’s level psychotherapist in 2002. While on US Army active duty he also became a Psychiatric Nurse Practitioner while working full time in 2011. He served as a Psych NP on active duty, to include a combat tour in Iraq, until his ‘retirement’ in 2014 and moved to Philippines with his 3 children. At this time he started medical school overseas at Oceania University of Medicine based out of Samoa accredited by Philippine Accrediting Association of Schools, Colleges and Universities (PAASCU). He continued to work as a Psych NP throughout medical school to support his children and to not have to take out loans for medical school tuition. Originally from Rhode Island, he completed medical school clerkship rotations throughout the USA with a graduation in May 2019 earning the esteemed credential of MD. He has successfully completed USMLE Steps 1, 2CS, and 2CK. He will take Step 3 this September as he applies for Psychiatry Residency. Having been and RN, NP and now MD, he is a believer of Physician led multidisciplinary healthcare teams 

  7 comments for “I Want My Slice of the Pie: Rationing of Health Care in the United States, An Inevitable Consequence of Increasing Health Care Costs

  1. Anna Kelly, MD
    August 13, 2019 at 6:08 am

    I work in the field of Addiction Medicine, sadly corrupted by Big Pharma more than I knew when I started 20 years ago. Curiously, it all began with Russell Portenoy and David Haddox (with whom I briefly worked) in the field of ‘Pain Management,’ advocating for the liberal prescribing of opioids and punishing doctors who knew about and tried to advocate for the multimodal/non-opioid approach to chronic pain. The punishment was in the label ‘opioidphobic.’ The good news is that I developed a clinical practice rooted mostly in lifestyle management–healthy diet–healing with whole foods, psychological health, movement, deprescribing many medications, etc. Real medicine is rooted in partnership and compassion, motivating the patient toward self-care, self sufficiency, and growth along spiritual lines. Given that most of what we treat are lifestyle diseases, patients have more power than they know over their own health, and to help them discover that is most meaningful indeed. Time to return to the roots of our own profession–helping the patients help themselves and stop trying to regulate and legislate ourselves out of the mess we helped to cause. Healthcare costs will fall dramatically….

  2. Jennifer Hollywood
    August 12, 2019 at 2:51 pm

    “So now another ethical problem emerging with the rationing of care. It’s likely not the private healthcare plans, nor the Cadillac plans that will ration, but those on the government plans of Medicare and Medicaid. ”

    I see mostly rationing by private health care plans. I see very little rationing by Medicare currently. I see some rationing by Medicaid, but not as much as private health insurance. I cannot comment on what may happen in the future, but my current experience is that the private plans are the MOST restrictive.

  3. Steve O'
    August 12, 2019 at 8:45 am

    We seem to gaze at the surface ripples in the problem, but never get much deeper than that.

    Certainly healthcare could and should be more efficient and effective. My view is that a transition to a free market would be the best, yet least likely, vector. More realistic is M4A, but in the short term I handicap the odds of its implementation at 5%, which leaves us with the current “unsystem”.

    Every robber knows the patter – “Your money or your life!” When the allocation and price of care is left to an organ of government to regulate, there is little motivation to fairness. “From each according to their abilities; to each according to their needs” is a fine phrase – but who is to guard the guardians themselves, who take what they consider reasonable for their own “needs?”
    “Efficient and effective” are qualities which are decided by the entity – government or corporation, the difference is minor.
    Supporting the Cult of Bureaucracy is an onerous burden. It determines that it, itself, is the one crucial nexus of the entire operation, much more important than the little twigs and branches that actually “do” something. Rather than leaving its own survival to the whim of reality – which states that the existence of every bureaucracy is justified only to the degree that it causes more worthy things to be accomplished than were it absent – it must create an illusion that it is the sole driving force for providing health, as an example.
    To do this, it must own the measures of quality, and it must be able to portray to a gullible public that there are shocking shortfalls in the Goals which only the Bureaucracy can detect, remedy and enforce.
    The Leviathan must market itself unceasingly. People must fear the consequences of the collapse of the National Healthcare industry – that it pumps the vital oxygen and nourishing nutrients for everyone’s survival into Existence.
    Direct Primary Care advocates are at heart, heretics. The desire for Healthcare comes from the individual’s recognition of suffering and death, and wishes to ameliorate such processes. But there it stops. It is the business of each to pursue wellness by their own rational standards, rather than through the massive bureaucracies which survive only by the threat – “Your money or your life!”

  4. Terry Nugent
    August 11, 2019 at 5:24 pm

    It is debatable whether or not the fact that nearly 20% of GDP is generated by healthcare is a blessing or a curse. Attempts to reduce the proportion assume that the resources deployed to health would be redeployed to more productive uses, but productivity is in the eye of the beholder. Which sectors would grow? Fashion? Defense?

    Certainly healthcare could and should be more efficient and effective. My view is that a transition to a free market would be the best, yet least likely, vector. More realistic is M4A, but in the short term I handicap the odds of its implementation at 5%, which leaves us with the current “unsystem”.

    Access to the highest quality of care is currently governed by a sub rosa free market. Those who can afford the best care get it, those who don’t settle for what’s covered. Physicians are cowed by third party purrs from recommending what’s best for patients

    The profession should rally around the Hippocratic oath and use the patient’s best interest as its North Star. The ancient moral compass stands the year of time.

    Organizations like the Practicing Physicians of America (https://practicingphysician.org)
    are striving mightily to serve as the conscience of medicine, advocating free of financial conflicts for what is right and just, to the extent that membership is free. That’s right, no dues! In my opinion they deserve the support of every conscientious physicians.

  5. Pat
    August 11, 2019 at 2:28 pm

    People can swear to whatever they wish, but the Classical Oath says nothing about an obligation to equity of care for all of society. “Whatever houses I may visit…” is not a call for universal care, but people continually try to beat physicians into government care with some Oath obligation that never existed.

    • Sir Lance-a-lot
      August 11, 2019 at 8:49 pm

      And, conversely, in the classical Hippocratic Oath the physician swears never to “cause an abortion.”

      I’m all in favor of abortion, and the more the better, including a few several decades postpartum, but sometimes, it seems, we fail to look honestly at our history, and seek to change its appearance for the sake of our modern whims.

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  6. Thomas David Guastavino
    August 11, 2019 at 2:03 pm

    Two things should be done immediately:
    1) Tort reform in the form of loser pays (Details upon request)
    2) Devote 100% of sin taxes to health care. (Details upon request)
    This is low hanging fruit and if we cant do this then we are not serious about solving the heath care cost “crisis”.

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