Healthcare rationing is already in place, of course, for uninsured people. If they qualify for care in public systems like the one in Houston's Harris County, where I live, it takes weeks to get through the administrative process and longer still to get an appointment at a clinic. And if a patient needs a specialist, that will mean another wait, which can lead to life-threatening delays in diagnosis and treatment. Medicaid (and soon Medicare) patients also face rationing of a sort, in that they often can't find doctors willing to treat them.
Paradoxically, even as costs are rising, hospitals and doctors are finding their work to be less and less profitable. Even the best insurance plan won't cover the entire cost of Mr. A's hospital stay these days, and Mrs. B's HMO may deny coverage for even a one-night hospital stay. Doctors who accept patients admitted from the ER are often working for free or paid a small subsidy by the hospital, and those who see uninsured or Medicaid patients in their offices are unlikely to recoup enough to cover their overhead for the visits.
Some efforts are being made to control costs. Hospitals keep an eye on "unnecessary days," and medical personnel are becoming experts on "cost-effective care." But the savings of such efforts are insignificant compared with what we spend on futile care at the end of life, or expensive tests and treatments that lead to better outcomes in only a tiny fraction of cases.
Even though President Obama's healthcare plan will expand the number of people with insurance, it won't change the reality that we cannot afford to give every patient and family all they want, or to provide four-star medicine when the three-star version is almost as likely to succeed. Decreasing payments for services will only force hospitals to close and doctors to stop accepting new patients.
Unless someone comes up with a rational program for deciding healthcare priorities, American healthcare is going to become too expensive for any but the rich — and for members of Congress. Don't we deserve better than that?