Reading more by Mark Thoma after following a link in my previous post, I found a post titled The Rationing Canard. In it he argues that the idea of rationing is a red herring. He ends with a good summary -- clear enough and short enough to quote in full. I don't agree (comments below), but again, at least he's getting his assumptions and goals out on the table.
The Republican attacks are, essentially:
Democrats intend or will be forced to reduce costs by reducing the number of people covered (perhaps focusing on the elderly) and by reducing procedures per person (i.e. a lower level of care on average). Dramatic tax increases may be needed as well.
The Democrat's response runs along the following lines:
That's a fabrication. There's no intent to reduce the number of people covered or to reduce the level/quality of care. In fact, the number of people covered must rise to achieve universal coverage, and procedures per person, i.e. the level of care, will only fall to the extent that procedures with little or no benefit are eliminated. The number of procedures (i.e. the quality of care) will, if anything, go up.
To achieve the goal of universal coverage while controlling costs, it is necessary that costs per person fall. However, this will not be achieved through rationing care. Instead, costs per person will be reduced by lowering the cost per procedure (through lower administrative costs, increased competition, lower drug costs, etc.) and by eliminating unnecessary procedures. Additional revenue may also be used to broaden coverage. Cross-country studies indicate that the reduction in costs per person needed to provide universal coverage without reducing the level of care is achievable.
The goal of Democrats is to lower costs without sacrificing the quality of care (which will allow coverage to be expanded). Whether that's achievable or not is a legitimate point to debate, I think the experience in other countries suggests there's quite a bit of excess in the system that can be removed without affecting the quality of care people receive, but accusing Democrats of intending to cut the quality of care or to ration care within particular segments of the population (or overall) mischaracterizes what they are trying to achieve.
His summaries of the Republican and Democratic positions may be correct. I can't judge. I disagree with that framing of the debate though because I think it loses sight of what's important.
* People maintain that we spend too much on health care for the benefits we get (both are hard to measure, but ...). If that's the case, we should be able to propose a way to cut costs w/o cutting benefits.
* People maintain that it is morally wrong to not provide a minimum standard of universal care. If we believe that -- or even if we don't as a society -- we should be able to propose a plan that will provide that universal standard and give the associated costs.
My conclusion is exactly the opposite of the author. Rationing isn't a canard, it is the key since people seem to be conflating the two points. By "paying" for universal minimum coverage by saying you can lower costs, you are making a rationing choice. Especially if you believe -- as the author attributes to the Democrats -- that there are significant cost savings to be had in high-cost/low-benifit procedures since there are by observation people out there who are willing to try those procedures.
It would be really refreshing for a politician to provide a plan for universal minimum health care including cost and actually force people to line up for or against it. It wouldn't pass -- it might even be political suicide because it would lead to being tarred as being in favor of arbitrarily raising taxes -- but as long as we don't have a proposal like that on the table, we are just being asked to trust some group of people to figure out a way to do something as they go. Which is kind of the "free-market" approach, but in this case it would be people working for some new or expanded government agencies.