Editing Socialized medicine (section)

===Rationing (access, coverage, price, and time)===
{{See also|Healthcare rationing in the United States}}

Part of the current debate about [[health care in the United States]] revolves around whether the [[Affordable Care Act]] as part of [[health care reform in the United States|health care reform]] will result in a more systematic and logical allocation of health care. Opponents tend to believe that the law will eventually result in a government takeover of health care and ultimately to socialized medicine and rationing based not on being able to afford the care you want but on whether a third party other than the patient and the doctor decides whether the procedure or the cost is justifiable. Supporters of reform point out that health care rationing already exists in the United States through insurance companies issuing denial for reimbursement on the grounds that the insurance company believes the procedure is [[Medical research|experimental]] or will not assist even though the doctor has recommended it.<ref>{{cite web |url=http://www.kmbc.com/r/6882159/detail.html |title=Man Dies After Insurance Co. Refuses To Cover Treatment |archive-url=https://web.archive.org/web/20120119100834/http://www.kmbc.com/r/6882159/detail.html |archive-date=January 19, 2012 |url-status=dead}} ABC station KBMC report on case featured by Michael Moore in Sicko!</ref> A public insurance plan was not included in the Affordable Care Act but some argue that it would have added to health care access choices,<ref name=patel/><ref name=scott/> and others argue that the central issue is whether health care is rationed sensibly.<ref name=McArdle/><ref name="leonhardt">{{cite news|first=David|last=Leonhardt|author-link=David Leonhardt|title=Health Care Rationing Rhetoric Overlooks Reality|url=https://www.nytimes.com/2009/06/17/business/economy/17leonhardt.html|newspaper=The New York Times|date=June 17, 2009|access-date=September 7, 2009|url-status=live|archive-url=https://web.archive.org/web/20110706001751/http://www.nytimes.com/2009/06/17/business/economy/17leonhardt.html|archive-date=July 6, 2011}}</ref>

Opponents of reform invoke the term socialized medicine because they say it will lead to health care rationing by denial of coverage, denial of access, and use of waiting lists, but often do so without acknowledging coverage denial, lack of access and waiting lists exist in the U.S. health care system currently<ref>{{cite web |quote=Over 95,000+ U.S. patients are currently waiting for an organ transplant; nearly 4,000 new patients are added to the waiting list each month. Every day, 17 people die while waiting for a transplant of a vital organ, such as a heart, liver, kidney, pancreas, lung or bone marrow. Because of the lack of available donors in this country, 3,916 kidney patients, 1,570 liver patients, 356 heart patients and 245 lung patients died in 2006 while waiting for life-saving organ transplants |title=25 Facts About Organ Donation and Transplantation |website=National Kidney Foundation |url=http://www.kidney.org/news/newsroom/fs_new/25factsorgdon&trans.cfm |archive-url=https://web.archive.org/web/20090711030138/http://www.kidney.org/news/newsroom/fs_new/25factsorgdon%26trans.cfm |archive-date=July 11, 2009 |url-status=deviated}}</ref> or that waiting lists in the U.S. are sometimes longer than the waiting lists in countries with socialized medicine.<ref>{{cite web |quote=Right now more than 8,000 people in the UK need an organ transplant that could save or improve their life. But each year around 400 people die while waiting for a transplant. |url=http://www.kidney.org.uk/donor.html |website=UK National Kidney Federation |title=Organ Donation |access-date=September 7, 2009 |url-status=dead |archive-url=https://web.archive.org/web/20100223044349/http://www.kidney.org.uk/donor.html |archive-date=February 23, 2010}} (Note: The UK population is about one sixth the size of the U.S. population).</ref> Proponents of the reform proposal point out a public insurer is not akin to a socialized medicine system because it will have to negotiate rates with the medical industry just as other insurers do and cover its cost with premiums charged to policyholders just as other insurers do without any form of subsidy.

There is a frequent misunderstanding to think that waiting happens in places like the United Kingdom and Canada but does not happen in the United States. For instance it is not uncommon even for emergency cases in some U.S. hospitals to be boarded on beds in hallways for 48 hours or more due to lack of inpatient beds<ref>{{Cite web  | last = Giffin  | author2 = Shari M. Erickson  | author3 = Megan McHugh  | author4 = Benjamin Wheatley  | author5 = Sheila J. Madhani  | author6 = Candace Trenum  | first = Robert B.  | title = {{title case|THE FUTURE OF EMERGENCY CARE IN THE UNITED STATES HEALTH SYSTEM}}  | publisher = Institute of Medicine of the National Academies  | date = June 2006  | quote = The number of patients visiting EDs has been growing rapidly. There were 113.9 million ED visits in 2003, for example, up from 90.3 million a decade earlier. At the same time, the number of facilities available to deal with these visits has been declining. Between 1993 and 2003, the total number of hospitals in the United States decreased by 703, the number of hospital beds dropped by 198,000, and the number of EDs fell by 425. The result has been serious overcrowding. If the beds in a hospital are filled, patients cannot be transferred from the ED to inpatient units. This can lead to the practice of "boarding" patients—holding them in the ED, often in beds in hallways, until an inpatient bed becomes available. It is not uncommon for patients in some busy EDs to be boarded for 48 hours or more.  | url = http://www.iom.edu/Object.File/Master/35/014/Emergency%20Care.pdf  | access-date = October 3, 2009  | url-status = live  | archive-url = https://web.archive.org/web/20081128203101/http://www.iom.edu/Object.File/Master/35/014/Emergency%20Care.pdf  | archive-date = November 28, 2008  }}
</ref> and people in the U.S. rationed out by being unable to afford their care are simply never counted and may never receive the care they need, a factor that is often overlooked. Statistics about waiting times in national systems are an honest approach to the issue of those waiting for access to care. Everyone waiting for care is reflected in the data, which, in the UK for example, are used to inform debate, decision-making and research within the government and the wider community.<ref>{{cite web|url=http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=1091|title=What does the Department of Health do? - Health Questions - NHS Direct<!-- Bot generated title -->|website=nhsdirect.nhs.uk|access-date=April 27, 2018|url-status=live|archive-url=https://web.archive.org/web/20071031075726/http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=1091|archive-date=October 31, 2007}}</ref><ref>{{cite web|url=https://www.canada.ca/en/health-canada/services/health-care-system/health-indicators.html|title=Health Indicators – Canada.ca|website=Government of Canada|date=December 19, 2006 |access-date=October 26, 2024}}</ref><ref>{{cite web |url=http://www.18weeks.nhs.uk/endwaiting/documents/EWCL_patient_LON_280907.pdf |title=Setting new standards for your care |access-date=September 14, 2009 |url-status=dead |archive-url=https://web.archive.org/web/20091012102149/http://www.18weeks.nhs.uk/endwaiting/documents/EWCL_patient_LON_280907.pdf |archive-date=October 12, 2009}} 2007 NHS patient leaflet on the 18 week maximum wait time promise for Dec 2008.</ref> Some people in the U.S. are rationed out of care by unaffordable care or denial of access by [[Health maintenance organization|HMOs]] and insurers or simply because they cannot afford co-pays or deductibles even if they have insurance.<ref>{{Cite news | url=https://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html | title=Why we must Ration Health Care | work=[[The New York Times]] | date=July 15, 2009 | quote=But if the stories ... lead us to think badly of the British system of rationing health care, we should remind ourselves that the U.S. system also results in people going without life-saving treatment&nbsp;— it just does so less visibly. Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits set by NICE. American patients, even if they are covered by Medicare or Medicaid, often cannot afford the copayments for drugs. That's rationing too, by ability to pay. | first=Peter | last=Singer | access-date=May 23, 2010 | url-status=live | archive-url=https://web.archive.org/web/20130515093406/http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?_r=3&pagewanted=all | archive-date=May 15, 2013 }}</ref> These people wait an indefinitely long period and may never get care they need, but actual numbers are simply unknown because they are not recorded in official statistics.<ref>{{Cite web |url=http://www.pnhp.org/reader/Section%208%20-%20Myth%20Busters/Myths%20as%20Barriers%20(Geyman).pdf |title=Myths as Barriers to Health Care Reform in the United States |access-date=June 12, 2008 |author=John P. Geyman |year=2003 |publisher=International Journal of Health Services |url-status=dead |archive-url=https://web.archive.org/web/20081024050345/http://www.pnhp.org/reader/Section%208%20-%20Myth%20Busters/Myths%20as%20Barriers%20(Geyman).pdf |archive-date=October 24, 2008}}</ref>

Opponents of the current reform care proposals fear that U.S. comparative effective research (a plan introduced in the stimulus bill) will be used to curtail spending and ration treatments, which is one function of the [[National Institute for Health and Care Excellence]] (NICE), arguing that rationing by market pricing rather by government is the best way for care to be rationed. However, when defining any group scheme, the same rules must apply to everyone in the scheme so some coverage rules had to be established. Britain has a national budget for public funded health care, and recognizes there has to be a logical trade off between spending on expensive treatments for some against, for example, caring for sick children.<ref>{{cite news |url=https://www.nytimes.com/2008/12/03/health/03nice.html |title=British Balance Benefit vs. Cost of Latest Drugs |website=[[The New York Times]] |date=December 3, 2008 |access-date=February 18, 2017 |url-status=live |archive-url=https://web.archive.org/web/20130515102140/http://www.nytimes.com/2008/12/03/health/03nice.html?_r=3&hp=&pagewanted=all |archive-date=May 15, 2013 |last1=Harris |first1=Gardiner }} Quote "Britain's National Health Service provides 95 percent of the nation's care from an annual budget, so paying for costly treatments means less money for, say, sick children." from NY Times article December 2, 2008</ref> NICE is therefore applying the same market pricing principles to make the hard job of deciding between funding some treatments and not funding others on behalf of everyone in the insured pool. This rationing does not preclude choice of obtaining insurance coverage for excluded treatment as insured persons do having the choice to take out supplemental health insurance for drugs and treatments that the NHS does not cover (at least one private insurer offers such a plan) or from meeting treatment costs out-of-pocket.

The debate in the U.S. over rationing has enraged some in the UK and statements made by politicians such as [[Sarah Palin]] and [[Chuck Grassley]] resulted in a mass Internet protest on websites such as Twitter and Facebook under the banner title "welovetheNHS" with positive stories of NHS experiences to counter the negative ones being expressed by these politicians and others and by certain media outlets such as ''Investor's Business Daily'' and Fox News.<ref>{{cite news |url=https://www.mirror.co.uk/news/uk-news/nhs-recieves-battle-cry-from-pm-412539 |title=NHS {{as written|rec|ieves [sic]}} battle cry from PM after attack from right-wing Americans |author=Jason Beattie |date=August 14, 2009 |newspaper=[[Daily Mirror]]}} Mirror (UK newspaper) on public reaction and rage in UK to Palin, Grassley, IBD, and Fox (Hanan) interviews intended to denigrate the NHS</ref> In the UK, it is private health insurers that ration care (in the sense of not covering the most common services such as access to a primary care physician or excluding pre-existing conditions) rather than the NHS. Free access to a general practitioner is a core right in the NHS, but private insurers in the UK will not pay for payments to a private primary care physician.<ref name="ABI"/> Private insurers exclude many of the most common services as well as many of the most expensive treatments, whereas the vast majority of these are not excluded from the NHS but are obtainable at no cost to the patient. According to the [[Association of British Insurers]] (ABI), a typical policy will exclude the following: going to a general practitioner; going to [[Emergency department|accident and emergency]]; drug abuse; HIV/AIDS; normal pregnancy; gender reassignment; mobility aids, such as wheelchairs; organ transplant; injuries arising from dangerous hobbies (often called hazardous pursuits); pre-existing conditions; dental services; outpatient drugs and dressings; deliberately self-inflicted injuries; infertility; cosmetic treatment; experimental or unproven treatment or drugs; and war risks. Chronic illnesses, such as [[diabetes]] and [[Chronic kidney disease|end stage renal disease]] requiring [[Kidney dialysis|dialysis]] are also excluded from coverage.<ref name="ABI">{{Cite web|url=http://www.abi.org.uk/Information/Consumers/Health_and_Protection/496.pdf|title=Are you buying private medical insurance? Take a look at this guide before you decide (Association of British Insurers, 2008)|publisher=[[Association of British Insurers]]|year=2008|access-date=September 5, 2009|url-status=dead|archive-url=https://web.archive.org/web/20100215035140/http://www.abi.org.uk/Information/Consumers/Health_and_Protection/496.pdf|archive-date=February 15, 2010}}</ref> Insurers do not cover these because they feel they do not need to since the NHS already provides coverage and to provide the choice of a private provider would make the insurance prohibitively expensive.<ref name="ABI"/> Thus in the UK there is cost shifting from the private sector to the public sector, which again is the ''opposite'' of the allegation of cost shifting in the U.S. from public providers such as Medicare and Medicaid to the private sector.{{Citation needed|date=September 2009}}

Palin had alleged that America will create rationing "[[death panels]]" to decide whether old people could live or die, again widely taken to be a reference to NICE. U.S. Senator Chuck Grassley alleged that he was told that Senator [[Edward Kennedy]] would have been refused the brain tumor treatment he was receiving in the United States had he instead lived a country with government run health care. This, he alleged, would have been due to rationing because of Kennedy's age (77 years) and the high cost of treatment.<ref>Audio of Senator Grassly repeating allegation Sen Kennedy would not receive care in the UK on grounds of his age. {{cite web |url=https://www.youtube.com/watch?v=QZK8ffUpL60 |title=YouTube |website=[[YouTube]] |access-date=November 28, 2016 |url-status=live |archive-url=https://web.archive.org/web/20160414063816/https://www.youtube.com/watch?v=QZK8ffUpL60 |archive-date=April 14, 2016 }}</ref>  The UK Department of Health said that Grassley's claims were "just wrong" and reiterated health service in Britain provides health care on the basis of clinical need regardless of age or ability to pay. The chairman of the British Medical Association, Hamish Meldrum, said he was dismayed by the "jaw-droppingly untruthful attacks" made by American critics. The chief executive of the National Institute for Health and Clinical Excellence (NICE), told ''The Guardian'' newspaper that "it is neither true, nor is it anything you could extrapolate from anything we've ever recommended" that Kennedy would be denied treatment by the NHS.<ref name="foreignpolicy.com">{{cite web |url=https://foreignpolicy.com/articles/2009/08/18/the_most_outrageous_us_lies_about_global_healthcare?page=0,0 |title=The Most Outrageous U.S. Lies About Global Healthcare {{pipe}} Foreign Policy |access-date=March 11, 2017 |url-status=dead |archive-url=https://web.archive.org/web/20130728041712/http://www.foreignpolicy.com/articles/2009/08/18/the_most_outrageous_us_lies_about_global_healthcare?page=0,0 |archive-date=July 28, 2013}}</ref> The business journal ''Investor's Business Daily'' claimed mathematician and astrophysicist [[Stephen Hawking]], who had ALS and spoke with the aid of an American-accented voice synthesizer, would not have survived if he had been treated in the British National Health Service. Hawking was British and was treated throughout his life (67 years) by the NHS and issued a statement to the effect he owed his life to the quality of care he has received from the NHS.<ref name="foreignpolicy.com"/><ref>{{Cite news | url=http://news.bbc.co.uk/2/hi/americas/8198084.stm | work=BBC News | title=Bloggers debate British healthcare | date=August 12, 2009 | access-date=May 23, 2010 | url-status=live | archive-url=https://web.archive.org/web/20100814233453/http://news.bbc.co.uk/2/hi/americas/8198084.stm | archive-date=August 14, 2010 }}</ref><ref>{{cite web |url=http://www.spectator.co.uk/alexmassie/5255761/stephen-hawking-has-not-yet-been-murdered-by-the-nhs.thtml |title=The Spectator |access-date=September 7, 2009 |url-status=dead |archive-url=https://web.archive.org/web/20090814202439/http://www.spectator.co.uk/alexmassie/5255761/stephen-hawking-has-not-yet-been-murdered-by-the-nhs.thtml |archive-date=August 14, 2009 }}</ref>

Some argue that countries with national health care may use waiting lists as a form of rationing compared to countries that ration by price, such as the United States, according to several commentators and healthcare experts.<ref name=patel/><ref name=scoring/><ref name=JPE/> ''The Washington Post'' columnist [[Ezra Klein]] compared 27% of Canadians reportedly waiting four months or more for [[elective surgery]] with 26% of Americans reporting that they did not fulfill a [[Medical prescription|prescription]] due to cost (compared to only 6% of Canadians).<ref name=ezra>{{cite news|url=http://voices.washingtonpost.com/ezra-klein/2009/06/a_rational_look_at_rationing.html|archive-url=https://archive.today/20130205182848/http://voices.washingtonpost.com/ezra-klein/2009/06/a_rational_look_at_rationing.html|url-status=dead|archive-date=February 5, 2013|title=A Rational Look At Rationing|newspaper=[[The Washington Post]]|access-date=September 7, 2009|date=June 17, 2009|author=Ezra Klein|author-link=Ezra Klein}}</ref><ref>{{Cite news |first=David |last=Gratzer |title=Canada's ObamaCare Precedent |url=https://www.wsj.com/articles/SB124451570546396929 |work=[[OpinionJournal.com]] |publisher=The Wall Street Journal |date=June 9, 2009 |access-date=September 1, 2009 |url-status=live |archive-url=https://web.archive.org/web/20150322085442/http://www.wsj.com/articles/SB124451570546396929 |archive-date=March 22, 2015 }}</ref> Britain's former age-based policy that once prevented the use of [[kidney dialysis]] as treatment for older patients with renal problems, even to those who can privately afford the costs, has been cited as another example.<ref name=patel>{{Cite book|url=https://books.google.com/books?id=XX_-rB07oP0C&q=Health+Care+Rationing&pg=PA360|title=Health Care Politics and Policy in America|author1=Kant Patel|author2=Mark E. Rushefsky|publisher=3rd Ed. M.E. Sharpe|year=2006|isbn=978-0-7656-1479-7|pages=360–361|url-status=live|archive-url=https://web.archive.org/web/20180427175646/https://books.google.com/books?id=XX_-rB07oP0C&pg=PA360&dq=Health+Care+Rationing#v=onepage&q=Health%20Care%20Rationing|archive-date=April 27, 2018}}</ref> A 1999 study in the ''Journal of Public Economics'' analyzed the British National Health Service and found that its waiting times function as an effective market disincentive, with a low [[Price elasticity of demand|elasticity of demand]] with respect to time.<ref name=JPE>{{Cite journal| first1 = S. | title = Rationing by waiting lists: an empirical investigation | journal = Journal of Public Economics | volume = 71| last1 = Martin | pages = 141–164 | year = 1999 | doi = 10.1016/S0047-2727(98)00067-X}}</ref>

Supporters of private price rationing over waiting time rationing, such as ''[[The Atlantic]]'' columnist [[Megan McArdle]], argue time rationing leaves patients worse off since their time (measured as an [[opportunity cost]]) is worth much more than the price they would pay.<ref name=McArdle>{{cite magazine |url=https://www.theatlantic.com/business/archive/2009/08/rationing-by-any-other-name/23049/ |title=Rationing By Any Other Name |author=Megan McArdle |author-link=Megan McArdle |magazine=[[The Atlantic]] |date=August 10, 2009}}</ref> Opponents also state categorizing patients based on factors such as social value to the community or age will not work in a heterogeneous society without a common ethical consensus such as the U.S.<ref name=patel/> [[Doug Bandow]] of the [[CATO Institute]] wrote that government decision making would "override the differences in preferences and circumstances" for individuals and that it is a matter of personal liberty to be able to buy as much or as little care as one wants.<ref>{{Cite web|author=Doug Bandow|title=Uwe Reinhardt on Health Care Rationing|publisher=[[CATO Institute]]|url=http://www.cato-at-liberty.org/2009/07/06/uwe-reinhardt-on-health-care-rationing/|access-date=September 7, 2009|author-link=Doug Bandow|url-status=dead|archive-url=https://web.archive.org/web/20090906173825/http://www.cato-at-liberty.org/2009/07/06/uwe-reinhardt-on-health-care-rationing/|archive-date=September 6, 2009}}</ref> Neither argument recognizes the fact that in most countries with socialized medicine, a parallel system of private health care allows people to pay extra to reduce their waiting time. The exception is that some provinces in Canada disallow the right to bypass queuing unless the matter is one in which the rights of the person under the constitution.

A 1999 article in the ''[[British Medical Journal]]'', stated "there is much merit in using waiting lists as a rationing mechanism for elective health care if the waiting lists are managed efficiently and fairly".<ref name=scoring>{{cite journal |title=Points for pain: waiting list priority scoring systems |author=Rhiannon Tudor Edwards |journal=[[British Medical Journal]] |date=February 13, 1999 |volume=318 |issue=7181 |pages=412–414 |doi=10.1136/bmj.318.7181.412 |pmid=9974435 |pmc=1114887 }}</ref> [[Arthur Kellermann]], associate dean for health policy at [[Emory University]], stated rationing by ability to pay rather than by anticipated medical benefits in the U.S. makes its system more unproductive, with poor people avoiding preventive care and eventually using expensive emergency treatment.<ref name=scott>{{Cite news|title=Doctors Say Health Care Rationing Already Exists|url=https://www.npr.org/templates/story/story.php?storyId=106168331|access-date=September 7, 2009|publisher=[[National Public Radio]]: [[All Things Considered]]|date=July 1, 2009|first=Scott|last=Horsley|url-status=live|archive-url=https://web.archive.org/web/20090904033216/http://www.npr.org/templates/story/story.php?storyId=106168331|archive-date=September 4, 2009}}</ref> [[Ethicist]] [[Daniel Callahan]] has written that U.S. culture overly emphasizes individual autonomy rather than [[communitarian]] morals and that stops beneficial rationing by social value, which benefits everyone.<ref name=patel/>

Some argue that waiting lists result in great pain and suffering, but again evidence for this is unclear. In a recent survey of patients admitted to hospital in the UK from a waiting list or by planned appointment, only 10% reported they felt they should have been admitted sooner than they were. 72% reported the admission was as timely as they felt necessary.<ref>{{cite web |url=http://www.healthcarecommission.org.uk/_db/_documents/Full_2007_results_with_historical_comparisons_-_tables.doc |title=National NHS patient survey programme, Survey of adult inpatients in the NHS 2007 |access-date=October 17, 2008 |url-status=dead |archive-url=https://web.archive.org/web/20081029031549/http://www.healthcarecommission.org.uk/_db/_documents/Full_2007_results_with_historical_comparisons_-_tables.doc |archive-date=October 29, 2008 |website=Healthcare Commission}}</ref> Medical facilities in the U.S. do not report waiting times in national statistics as is done in other countries and it is a myth to believe there is no waiting for care in the U.S. Some argue that wait times in the U.S. could actually be as long as or longer than in other countries with universal health care.<ref>{{cite web |url=http://www.businessweek.com/magazine/content/07_28/b4042072.htm |title=The Doctor Will See You-In Three Months |access-date=October 30, 2008 |url-status=dead |archive-url=https://web.archive.org/web/20081007064527/http://www.businessweek.com/magazine/content/07_28/b4042072.htm |archive-date=October 7, 2008 |website=Business Week}}</ref>

There is considerable argument about whether any of the health bills currently before congress will introduce rationing. [[Howard Dean]] for example contested in an interview that they do not. However, ''[[Politico]]'' has pointed out that all health systems contain elements of rationing (such as coverage rules) and the public health care plan will therefore implicitly involve some element of rationing.<ref name=scott/><ref name=dean>{{Cite web|url=http://www.politifact.com/truth-o-meter/statements/2009/aug/25/howard-dean/rationing-health-care-reform/|title=There's rationing in health care now, and there still would be under reform bill|publisher=[[PolitiFact]]|access-date=September 7, 2009|url-status=live|archive-url=https://web.archive.org/web/20090830200720/http://www.politifact.com/truth-o-meter/statements/2009/aug/25/howard-dean/rationing-health-care-reform/|archive-date=August 30, 2009}}</ref>