The ACP Advocate Blog
by Bob Doherty
Thursday, September 24, 2009
"You can't always get what you want . . .
. . .But if you try sometimes, well you might find,
You get what you need."
So sings Mick Jagger in this rousing refrain from the hit song on the Rolling Stone's 1969 "Let it Bleed" album.
Most people wouldn't look to Mick Jagger and Keith Richards as a source of child-raising advice. But I have quoted this phrase many, many times to my kids. Like when my 17 year old daughter recently insisted that she needed a "cool" new cell phone, when she already had a perfectly good phone. Of course, telling her that "you can't always get what you want" didn't help my approval rating that night.
The advocates of health care reform are dealing with something similar. What people want is unlimited health care, paid for by someone else, at no cost to them. What they need is access to care that is reasonably affordable, with some limits to ensure that the total price tag doesn't bankrupt the country.
It is the "limits" part that has people upset. They instinctively understand that health care reform will involve some limits on their own care, even as heath reform advocates try to sugar-coat things by saying it can all be paid for by reducing waste and fraud and promoting "value" and "efficiency" in health care. We can deny all we want that health care reform will lead to rationing, yet much of the public believes that in the end, the government will put limits on the care they want.
I think this explains the ambivalence about health reform in recent polls. The Kaiser Family Foundation's August tracking poll found that 45% of voters felt that health care reform would make "the country as a whole" better off but only 36% felt it would do the same about them and their families. Only 29% thought it would make the quality of care better for them personally, but 37% thought it would make quality "in America" better. 42% thought that it would make wait times for non-emergency treatments personally worse for them. 51% were more worried that Congress would pass a bill that won't be good for them and their family, compared to the 39% that were more worried that Congress wouldn't pass a health care reform bill this year.
The public's concern about the impact of health care reform on them personally is appropriate and understandable. President Obama has tried to blunt this by emphasizing how people with health insurance will benefit from reform, and some other recent polls suggest that he is making progress.
I think the President has not squared with the American people that it isn't possible for everyone to get everything they want. But the critics of his efforts have also done a disservice by screaming "rationing" every time the discussion turns to controlling costs.
The issue, in my mind, is not whether there will be limits - call it rationing if you must, although it is such a loaded term. Instead, the question is who will do the rationing and how. Should we continue to leave it to insurance companies to limit services by denying coverage for people with pre-existing conditions, cancelling coverage when they get ill, and finding every possible reason to deny claims for services?
Should we do it based on who has access to health insurance and who doesn't? By how rich your benefits package is? By whether you work for an employer who can provide coverage, or whether you work for a small company that cannot? By giving everyone a high deductible plan so they are more responsible for the cost of their own care? By making smokers and others who have so-called "lifestyle" illnesses pay more? By having the government fund research on the clinical effectiveness of different treatments and then designing benefits, coverage, and payment policies around such research?
Good arguments can be made for, and against, almost all of these approaches, but at least they recognize the simple fact that when it comes to health care, you can't always get what you want, but if you try sometimes, well you might find, you get what you need.
Today's question: Do you think it is possible to engage the public in a rational discussion about rationing?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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