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BOOK REVIEWSIs Rationing Right For Americans?Can We Say No? The Challenge of Rationing Health Care by Henry J. Aaron and William B. Schwartz, with Melissa Cox (Washington: Brookings Institution Press, 2005), 211 pp., $44.95 (cloth), $18.95 (paper)
Everything Henry Aaron writes about health care is worth reading, including this busman’s holiday of a book on what we should learn from the British health system. He and his coauthors offer a brief history of the National Health Service (NHS), its strengths and weaknesses. Thanks to Tony Blair and more affluent and assertive patients, government health care in Britain is better funded and more flexible than it used to be. Aaron and colleagues believe that skyrocketing spending in the United States will force rationing of health care. He is absolutely correct that projected increases in Medicare, Medicaid, and private insurance spending are unsustainable. After reviewing failed U.S. attempts to limit spending growth and, in his view, the paucity of other options, he invokes the dreaded "R" word to describe possible "administrative controls" on the supply of health care. Aaron sees the British experience as instructive even as their system begins to show signs of convergence with our own. How do the Brits stay so healthy at half the price? The authors’ short answer is that for procedures ranging from computed tomography (CT) scans to angioplasty, they probably spend too little and we too much. Aaron is a great scholar (this is an update of his 1984 book on the same subject), but the evidence here is necessarily impressionistic and occasionally anecdotal. It is also of dubious relevance to the U.S. health system. After all, the NHS was born after decades of austerity and the terror of the Blitz to socialist parents who were also stoics with stiff upper lips. Delivery of the baby was reluctantly assisted by British physicians, who still maintain that everyone over age fifty-five is "a bit crumbly" and therefore may not deserve, for example, kidney dialysis. In the United States, these same fifty-five-year-olds have already joined AARP and demanded, as they did in 2003, an unfunded $8.1 trillion Medicare drug bill. British general practitioners (GPs) and consultants are unreliable guides for U.S. reform because they usually tell pollsters that they favor more medical care than they, in fact, prescribe. Working for salaries that are considered paltry by their American counterparts, British doctors apparently use "moral suasion" to enforce a thrifty medical system that does empower them to "say no." Getting Parliament to tame malpractice lawyers and pay your malpractice premiums also helps reduce the amount of defensive medicine. This book tends to idealize government care ("the NHS still remains the best place for complex procedures"—tell that to Pinochet!) and to underestimate the strong supporting role of private-sector care in the United Kingdom, sometimes called Harley Street medicine. Aaron and colleagues admit that private care in Britain attracts 19 percent of total health spending but dismisses this as a "safety valve" that is "disproportionately located in and around London and the relatively wealthy southwest." If this is where most Britons want to live, is demand for private care a safety valve or a sign of the future? Another ominous sign for the NHS is British private health insurance, which undermines government-provided care by allowing the jumping of queues and bypassing of NHS hospitals. Such private insurance is a popular perk. Although only 11 percent of the total population is covered, 22 percent of successful executives, managers, and professionals are. Regarding U.S. policy options, Aaron and colleagues prefer to limit care for the well-to-do. This is refreshing, because Congress tends to be hardest on the poor by scape-goating Medicaid benefits. But the authors go too far when they define rationing as "the denial of some beneficial care to some people who have the financial means to pay for it." You can’t ration rich people in free countries, at least if they are not hurting anyone else. First, it’s impractical because they will dodge limits even if they must leave the country. Second, it may violate their constitutional rights. After the 2005 Canadian Supreme Court decision enshrining the right to private health care in a single-payer system, U.S. courts will probably uphold even broader treatment options in a land of "life, liberty, and the pursuit of happiness." The authors’ antipathy for the well-to-do emerges in their discussion of charity-funded health care: Such gifts are not simply expressions of charitable impulses. They are also a special kind of safety valve permitting individuals or communities to buy medical services that the budget does not support. Whatever the motivation for such gifts, the authorities must decide what to do about them (p. 149). Only the most ardent global-budgeteer would want "authorities" to "decide what to do about them"—that is, presume to tell Americans how to spend their own money. Although health charities are minor in the United Kingdom, in 2004 they received $22 billion in the United States, third only to educational and religious institutions.1 So how can Americans get healthier for less? The answer must include restraints on both the supply and demand for care, and for patients of all income levels. The more palatable the restraints, the earlier they can be adopted in a democracy. Although the "R" word might be a useful pedagogic device, it is political dynamite that scares people and delays the chances for any reform. Rationing, as the authors note, is often associated with the mindless denial of care. Although Aaron and colleagues are confident that denial of care can be done intelligently, patients are unlikely to agree. Americans should get the first chance to limit their own health spending. Once they learn the true cost of what they are buying, share a larger portion of the cost, and can judge the benefits—if any—of treatment options, then they will choose more wisely than the government. Once they learn how healthier lifestyles can save them money, preventive care might finally flourish. The authors underestimate the role of markets in curbing health spending. For example, they completely ignore so-called consumer-driven health plans in the United States. Such plans might not ultimately work, but that form of individual self-rationing must be tried first before other forms of rationing can be attempted. The sooner we empower the individual, the sooner we can tell whether we need Aaron and colleagues’ governmental solutions. We can learn much from our friends across the Atlantic, but it’s too early to say whether we need Anglophilia to cure our hypochondria.
Editor's Notes Jim Cooper (D-TN) is serving his eighth term in the U.S. House of Representatives. He is a member of the House Armed Services and Budget Committees. NOTE
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