Can We Say No?

Can We Say No?: The Challenge of Rationing Health Care

Henry J. Aaron
William B. Schwartz
with Melissa Cox
Copyright Date: 2005
Pages: 199
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  • Book Info
    Can We Say No?
    Book Description:

    Over the past four decades, the share of income devoted to health care nearly tripled. If policy is unchanged, this trend is likely to continue. Should Americans decide to rein in the growth of health care spending, they will be forced to consider whether to ration care for the well-insured, a prospect that is odious and unthinkable to many. This book argues that sensible health care rationing can not only save money but improve general welfare and public health. It reviews the experience with health care rationing in Great Britain. The choices the British have made point up the nature of the options Americans will face if they wish to keep public health care budgets from driving taxes ever higher and private health care spending from crowding out increases in other forms of worker compensation and consumption. This book explains why serious consideration of health care rationing is inescapable. It also provides the information policymakers and concerned citizens need to think clearly about these difficult issues and engage in an informed debate.

    eISBN: 978-0-8157-9794-4
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Foreword
    (pp. vii-x)
    Strobe Talbott

    Of all the challenges facing the United States, one of the most daunting and important is the growing inadequacy of our national health care system. Sound analysis of the problem and constructive recommendations on the solution—or, as my colleague Hank Aaron would put it, accurate diagnosis combined with effective prescriptions—is a major institutional commitment of the Brookings Institution. We’re lucky to have had Hank on our staff since 1967 and on the cutting edge of this issue for the last twenty-six years, and we’re proud to be publishing this book as a contribution to the search for...

  4. Acknowledgments
    (pp. xi-xiv)
  5. CHAPTER ONE The Promise and the Problem
    (pp. 1-10)

    The good news is that modern medicine works miracles. The bad news is that it breaks banks—public and private. The benefits from improved health care exceed by trillions of dollars its admittedly large and growing cost.¹ Before the late 1960s and the development of durable artificial hips, for example, it was impossible to enable people crippled by painful, arthritic hips to walk normally again. Before the invention of computed tomography (CT) scanners or magnetic resonance imaging (MRI) it was often impossible—short of invasive, painful, and costly exploratory surgery—to pinpoint the exact location of many deep tumors or...

  6. CHAPTER TWO The British System
    (pp. 11-29)

    In a famous exchange, Ernest Hemingway wryly responded to F. Scott Fitzgerald’s observation that “the rich are different from you and me” by saying, “Yes, they have more money.” In comparing the American and British health care systems, a Fitzgerald-like comment would be that the health systems of the two nations differ because of history, politics, and medical institutions. A Hemingway-like response would be that Americans spend more than twice as much as the British do.¹

    Although Britain spends far less per capita on medical care than does the United States, it has 13 percent more acute care hospital beds...

  7. CHAPTER THREE Matters of Life and Death
    (pp. 30-58)

    New ways to prevent death constitute some of the most spectacular and costly advances in health care:

    —Death from chronic, severe kidney failure was sure and swift until machines were invented that could replace many of the excretory functions of the kidney and ways were found to prevent or slow the failure of kidney transplants.

    —Victims of hemophilia, the bleeding disease linked in history texts to royalty, could not be effectively treated until the key blood constituents that produce normal clotting were isolated. Now, hemophilia’s devastating symptoms can be treated. Its victims, though never cured, can live almost...

  8. CHAPTER FOUR Quality of Life
    (pp. 59-76)

    Tight budgets, one might think, would more severely limit care that “merely” improves the quality of life than care that saves lives. The story is a good deal more complicated, however. Discomfort may be acute, unremitting, and disabling, or it may be merely annoying and inconvenient. The benefits of surgery providing artificial hips that return bedridden and pain-racked invalids to pain-free mobility are at least as great as the gain from briefly extending the life of terminally ill, semicomatose patients. Furthermore, replacing arthritic hips may cost less than custodial care required for patients immobilized by arthritis of the...

  9. CHAPTER FIVE Diagnoses
    (pp. 77-92)

    Patients are sometimes comforted by the myth that physicians are inerrant, a delusion some unkind medical critics allege that physicians welcome. This belief that physicians seldom err has certain advantages: it increases patients’ willingness to adhere to prescribed regimens, and it alleviates anxieties that can obstruct recovery. But as all competent doctors and well-informed patients realize, it is false. In fact, physicians are usually at least a bit unsure about the precise cause of various signs and symptoms, as well as about the best method of treatment.

    Physicians acquire information in many ways. They ask questions. They perform physical...

  10. CHAPTER SIX Rationing and Efficiency
    (pp. 93-107)

    Health care rationing can be done efficiently or inefficiently. This chapter explains the principles that must apply to ensure that whatever is spent on health care yields the largest possible overall benefits. Chapter 8 will raise questions about whether the U.S. political and health care systems are well designed to achieve this outcome.

    People are usually assumed to spend their incomes to get as much satisfaction from them as possible. In the jargon of economics, free consumer choice is assumed to be “efficient.” Efficiency means that consumers cannot improve their overall satisfaction by buying less of something and more of...

  11. CHAPTER SEVEN Efficiency and Inefficiency in British Health Care
    (pp. 108-130)

    Efficiency in the use of medical resources requires that all carenotprovided be less valuable than any care thatisprovided.¹ No medical system passes this test. Every country, even those in which services are severely rationed, wastes some resources because of correctable clinical errors that misdirect services to patients who are unlikely to benefit from them. But the evidence reported here confirms that the British system fails the test of efficiency in another sense. While some services are provided up to or near the point at which medical benefits are maximized, whole categories of services receive so few...

  12. CHAPTER EIGHT Rationing Health Care in the United States
    (pp. 131-148)

    Many Americans find unthinkable the idea that the United States might one day ration medical care. The fact that millions are entirely uninsured or lack adequate coverage is widely accepted, if regretted. However, in a strange exercise in mental compartmentalization, limits on care for those with good health insurance or enough money to pay seem strange and unthinkable. Yet continuation of past rates of growth in health care spending portend unprecedented government deficits, rising numbers of uninsured, and narrowed capacity of U.S. workers to enjoy increases in other forms of consumption.¹

    To be sure, future increases in health care spending...

  13. APPENDIX Frequency of Surgery
    (pp. 149-154)
  14. Notes
    (pp. 155-194)
  15. Index
    (pp. 195-200)
  16. Back Matter
    (pp. 201-203)