There is a serious cost problem in USA health care which no one denies.

Yet when it comes to suggested solutions, there is a wide divergence of opinion.  Attempts to use experts and evidence based guidelines for care are somehow viewed as government interfering with decisions which should be between the doctor and her patient.

States and insurance schemes have made varying attempts to deal with this.  The Oregon Health Plan is a good example of an attempt to match funding with needed care.  Unfortunately to date the need has far outstripped funding.  But Oregon had an interesting idea.

Why not bring physicians, consumers, advocates, interested groups and see where limited dollars should be spent – basically where can we get the best “bang for the buck” in a given population.  Long lists of preventable and treatable illness were made up and, in a transparent way, coverage was designed for best use of the dollars.  This is what I would call rational rationing.  We only have so much money for health care (currently up to 17% of GDP), it’s not infinite, and it’s already impinging out ability to funds schools, infrastructure, etc.

We are spending 50% more in health care services in the USA than other developed nations, yet our longevity and health outcomes are equivalent to Slovenia and Costa Rica, less developed nations.  About 35 million people in our country have no medical insurance.  It was suggested in political debates that they can go to any emergency room, but that of course is delayed and fragmented care which actually drives up costs.  I saw a 40 year old waitress in my office after she coughed up blood.  Her diagnosis was lung cancer.  There was no funding for radiation treatments or chemotherapy or even palliative care.  I felt so badly when I couldn’t effectively guide her care.

So it’s pretty obvious that we do ration care in the USA.  We do it by ability to pay, with a poor safety net for those unable to pay.  Several Presidents beginning with Theodore Roosevelt have tried to reform health care without success.  The current reforms, essentially modeled after those in Massachusetts promoted by then Governor Romney, are now under attack by none other than Romney himself.  Romney decries the attempts to control Medicare costs in the Affordable Health Care Act (now called Obamacare).

Here’s a thorough debate on the subject of end-of-life rationing.  A live audience is polled before and after to see which debating team “won.”

Jim deMaine is a pulmonary physician who blogs at End of Life – thoughts from an MD.