(Jonathan Ernst/Reuters)

I believe our would-be technocratic overlords had a two-step plan: First, pass Obamacare to centralize federal control over the health-care system. After that, use the cost-cutting mechanisms embedded into the law to institute health-care rationing, or as Sarah Palin famously called it, to establish “death panels.”

Step one succeeded, but has been blunted by subsequent events, such as removing the individual mandate penalty and the destruction of the Independent Payment Advisory Board.

But that has not impeded the overarching plan. Despite Obamacare’s troubles and in anticipation of “Medicare [really, Medicaid] for All,” rationing is now being brought to the fore in an editorial just published by the highly influential Journal of the American Medical Association. Claiming that rationing is “an inevitable consequence of increasing health care costs,” the JAMA editorial concludes:

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. It has been said many times that in the richest country in the world, in which 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.

That sounds like forced redistribution of medical resources to me.

There are several things to ponder about this. Here are a few that immediately pop into my mind:

One of the reasons for increased health-care costs is illegal immigration. California pays for the health-care costs of people here illegally, creating quite a magnet for poor and ill people from all over the world to sneak into the United States. So too, New York City plans to guarantee coverage by sliding-scale health insurance for anyone living in the city, whether legally in the country or not. Of course,“free” ain’t free. Will the American people accept having their access to health care restricted as a partial consequence of society covering the non-emergency medical costs of people with no legal right to be here? The scope of health care is expanding beyond curing illnesses and repairing injuries to include treatments to ameliorate unhappiness or to overcome biological impediments to what one yearns for or to become. The cost of these interventions really add up. Medicare has paid hundreds of millions to enable older men to have sexual relations — whether the difficulty is caused by disease or not — even though diminishing potency is a natural part of aging. Expensive treatments for gender dysphoria are paid by Medicare, and the Obama administration required they be covered under Obamacare. Meanwhile, California requires health insurance obtained through work to cover fertility procedures, including for gay people who aren’t biologically infertile. Most health-care rationing schemes are invidiously administered. For example, will we ration based on age, say, by disallowing heart surgery coverage for 80-year-old patients regardless of the individual’s ability to benefit from such care? (Remember President Obama telling a woman, whose 100-year-old mother was successfully treated with a pace maker, that sometimes we just have to tell the elderly they are better off “taking the pain killer”?) Or, will we decide that rationing will be based on “quality of life,” as is done in the “quality adjusted life year” (QALY) system — pushed notably by the New England Journal of Medicine — which medically discriminates against the elderly and people with disabilities? Will health-care rationing increase the pressure to legalize assisted suicide? I believe that many in the medical intelligentsia and bioethics would be fine with that. Many already support assisted suicide ideologically. Besides, what could be a cheaper “treatment” than giving an overdose of drugs? This paradigm has already played out in Oregon where Barbara Wagner was denied life-extending chemotherapy on rationed Medicaid, but offered payment for assisted suicide. Rationing pits groups of people against each other — the disabled versus the young, versus the elderly, and people living with AIDS or cancer — as they fight for parts of a limited resource pie. In such a milieu, those with political power are rarely rationed. Those without influence face restrictions. Rationing disempowers patients. If a health-insurance company refuses to pay for a treatment that should be covered under the contract, there are methods of redress. Indeed, trial lawyers salivate about such cases. If the government decrees care will not be covered, you are out of luck except for mind numbing and usually futile administrative appeals.



Rationing will mean long waits for surgery and tests (as in Canada). It will destroy trust in medicine and create conflict between patients and their doctors. It will stifle the drive to create new and innovative treatments that offer great hope to suffering people. And, unless the entire system is socialized, as in Canada, the rich will always be able to pay for and receive whatever health care they want. Actually, that’s precisely what happens in Canada as the rich can “jump the queue” by coming here for treatment.

So, good luck JAMA. I don’t think that the American people want to empower bioethicists to be the gatekeepers of their access to medical treatment. Nor will we accept the bureaucratic authoritarianism that rationing requires.

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