Health Care Reform: The Difference Between Rationing and Rational

June 22, 2009— -- For a number of years I have enjoyed an invitation to submit opinion essays for consideration for posting in the Health Section on ABCnews.com. Gratifyingly, many have been deemed worthy and dozens are archived.

I am not paid by ABC. For that matter, I am not a paid consultant to any component of the health care industry except by the State of North Carolina for my roles as a professor of medicine on the faculty of the School of Medicine of the University of North Carolina. I have a vested interest in the care of the patient and in the teaching of that caring, and I refuse to compromise that ministry.

In several recent opinion pieces on ABCnews.com I broached the hot-button topic of effectiveness. I asserted in no uncertain terms that many of the things we offer American patients, and many of the things we do to American patients afford them no personal advantage. I based these arguments on a comprehensive and compelling science.

Much to my surprise, I learned that my name and my arguments were bandied about in segments of the media as advocating the rationing of health care. Out of curiosity, I agreed to a "talk radio" interview on this topic on May 27.

The host wasted no time in confronting me as an agent of the White House preparing the country for a health care reform agenda that entailed rationing of health care services. I made it clear that I have no formal consultative relationship with any federal agency. I always speak on behalf of my patients, my students and colleagues, and my personal ethic. Once that was established, we were able to dispassionately address the notion of rationing. I hope we can do so again, here.

Firstly, it is interesting that "rationing" has become a toxic buzzword in the context of health care. Rationing is the act of apportioning a fixed amount of a finite resource. The "finite resource" we are apportioning annually for "health care" in the United States is $3 trillion. That's much greater per capita than the apportionment of any other resource-advantaged country.

Furthermore, our current apportionment manages to exclude some 30 percent of the workforce, and many others. No other resource-advantaged country apportions so unevenly, if they apportion unevenly at all. I hear very little advocacy for decreasing our $3 trillion finite resource. Bizarrely, there is advocacy for further increasing this finite resource. The arguments I hear relate to the fashion in which our finite resource is apportioned.

I and many others have strong thoughts about this apportionment. No one advocates wasting money. To the contrary, we are swimming in plans to decrease the waste that is consequent to inefficiencies in delivery and in the quality of performance. There is no argument.

There is also no argument about ineffectiveness. If some medical or surgical act does not advantage me or my family or my patients, it shouldn't be done. I don't care how well it is done, how cheaply it is done, how efficiently it is done; if it doesn't work, don't do it.