Rationing Medical Care

By John Elson

Which is more valuable? To provide a $150,000 liver transplant for an ailing child of indigent parents? Or to use that money for prenatal care that may enhance the life expectancy of fetuses being carried by 150 expectant mothers? To most Americans, the either/or aspect of the question is morally repugnant -- surely the leader of the democratic capitalist world can afford both. Yet a growing number of health experts argue that the U.S., in fact, no longer has the financial resources to provide unlimited medical treatment for all those who need it. The only solution, they say, is rationing health care.

The state of Oregon and California's Alameda County, which includes Oakland, are on the verge of taking that seemingly drastic step. In April, the Oregon senate passed a bill that would extend Medicaid coverage to 86,000 low-income people previously not covered. There would, however, be limits to the care they could expect. The measure, now before the lower house, would also establish a commission of experts and consumers to rank health services in order of importance; the legislature would then decide which to finance. Oregon has already set up committees of doctors, nurses and social workers to & establish priorities in four medical categories covered by Medicaid. Prenatal care, nutrition, immunizations, birth control and abortions rank high on the lists, while organ transplants and cosmetic surgery have been given low priority.

In Alameda County, the board of supervisors last January hired a professional ethicist to assist a committee of medical experts in deciding what specific services will be made available to the county's uninsured poor. "It's scary," says Dr. Marye L. Thomas, Alameda's director of mental health and a member of the committee. "As a physician, I was trained to give the best possible care to anyone, period. Back when I was in medical school, I never thought I would be discussing this."

Health officials cite grim statistics as evidence that they are acting out of fiscal need, not cruel disregard for human suffering. In Alameda, roughly 75% of the county's $278 million health-care budget comes from state and federal sources. But that money is drying up. For example, state funds are currently only about one-half of what the county received in 1982. Health administrators argue that rationing is a pointed way of telling legislators they must bear the responsibility for their budgetary decisions.

In a sense, rationing medical care is a form of triage -- the mellifluous French term, derived from wartime practice, for giving medical attention to the most likely survivors. This goes against the American grain. According to a 1987 Harris poll, more than 90% agreed with the statement that "everybody should have the right to get the best possible health care -- as good as the treatment a millionaire gets." But another survey, by the Public Agenda Foundation, found that only one person in ten would accept a $125 tax increase to support a national insurance program for catastrophic illness. As medical costs rise at an annual rate of more than 15%, public health facilities try to cope with the needs of the 37 million Americans -- about 15% of the population -- who have no medical insurance at all. "We want to be all things to all people, but the money's just not there," says Dr. Tom Miller of Alameda County's public health department.

The experts who favor rationing as a solution note that the reality of it is not new. In 1987 Oregon decided that it would no longer pay for organ transplants for Medicaid patients, even as the legislature added $5 million to the state budget for prenatal care. Many doctors readily admit that applicants for new high-tech operations have to pass a "green screen" or "wallet biopsy" -- meaning those who can pay get first crack at the operations.

Daniel Callahan, director of the Hastings Center, which specializes in the study of bioethical issues, approves the pioneering steps being taken by Oregon and Alameda. Trying to contain medical costs by greater efficiencies is "wishful thinking" in his view. One reason is the inexorable aging of America, as the nation's over-65 population rises from about 28 million today to a projected 35 million by the year 2000. Callahan also blames high-tech research for producing ingenious new operations that remain astronomically pricey even as they become popular and desirable. He proposes a slowdown on developing gimmicky procedures like artificial hearts and a more careful review of their social and economic consequences. Says he: "We keep inventing new ways to spend money, and that complicates things."

In response, Dr. David Rothman of New York City's Columbia-Presbyterian Medical Center notes, "This is not a country that has ever turned its back on new technology." On the broader issue of rationing, many opponents argue that the new Oregon and Alameda County regulations are inherently unfair, since the limits on health-care protection apply only to the poor, particularly the young. Dr. Sam Flint, a director of the American Academy of Pediatrics, notes that children account for roughly 50% of the Medicaid population but receive only about one-fifth of health-care dollars. Meanwhile, the elderly get about 40% of those funds.

An Oregon lawmaker opposed to the bill is Democrat Tom Mason. "You can't approach medicine merely as the greatest good for the greatest number of people," he says. "If we do that, why should anyone take care of you after a horrendous traffic accident?" A fair question, since it points to the medical reality that what is merely an option for one individual can be a life-or- death matter for another. Still, until the U.S. is ready for the huge fiscal sacrifices that would make complete medical care available to all, some form of rationing -- with rules clearly established and given community support -- may be the only fair and practical answer.

With reporting by Mike Cannell/New York and Dennis Wyss/San Francisco