Rationing health care is our choice

The Obama administration believes that health care can be made cheaper without any reduction in quality. It has evidence to back this up. According to the famous Dartmouth studies, (health care) costs two or three times as much per person in some places in America as it does in others, with no measurable difference in results. Atul Gawande's deservedly admired recent essay in the New Yorker makes a similar point. So in theory it's easy: Just figure out how the cheap places do it and apply this knowledge to bring down the cost in the pricier places.

But that doesn't mean rationing will be easy to avoid. Statistics on life expectancy or infant mortality are averages. The easiest way to raise your averages — maybe even the best way, if we're being honest — is to concentrate on the general level of care and not to squander a lot on long-odds cases. But if the long-odds case is you or a family member, you may well feel differently.

In the debate about how to reform health care, “how” means two different things. One is the industry structure: Should we simply nationalize the whole system or set up a government alternative to operate alongside the private one? Or are there novel market-based alternatives that ought to be tried? Gawande thinks the problem is a culture of medicine that has become too greedy. Others believe that human greed is a given and that either the government or the market will have to do a better job of controlling it. The other “how” is how the actual course of treatment for patients will change. Here there is much less to debate. Cheaper treatment means less treatment: fewer tests, fewer surgeries, fewer drugs.

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