Straight Talk about Rationing

Among the many reasons given for the utter collapse of the Clinton administration's health reform initiative is the failure of that initiative to openly address the issue of rationing [1, 2]. The leadership of the Domestic Health Policy Task Force, including Ira Magaziner, firmly believed that explicit talk of rationing was political suicide. Critics of Hillary Clinton's task force insisted that attempting to sell the American public on a plan for reform that would rein in costs and expand coverage for the uninsured without acknowledging the necessity of some form of rationing was, at best, dishonest [1-3].

Although there will be no systematic national effort to reform the delivery of health care for many years, the need for an autopsy of the recently deceased health reform effort is real. Although the private sector and state governments must now carry the health reform ball in the United States, the question still remains: Is rationing inevitable [1-5]? If so, can Americans talk publicly and reasonably about how to ration? A report from the Health Care and Medical Priorities Commission of the Swedish Ministry of Health and Social Affairs, No Easy Choices: The Difficult Priorities of Health Care [6], accepts rationing as inevitable and provides an important example of how the subject can be publicly addressed.

The Commission's task was to arrive at ethical values and principles that could be used by the national government to stimulate debate and discussion about rationing in the Swedish health care system. American readers still reeling from the Clinton debacle will be interested to learn that the term “rationing” is never used. The Commission, which was created in 1992, is referred to as the Priorities Commission throughout the report and in subsequent reports in the press and academic journals. Talking about setting priorities rather than about rationing seems to have let the Swedes travel much further down the road to health reform than Hillary Clinton and her supporters could by avoiding any talk of rationing at all.

The motivation for having a committee attempt to define core principles to guide public debate about priorities is not unfamiliar to those who live on this side of the North Atlantic; that motivation is the perception of a growing gap between the need for health care and the resources to meet that need [6]. The Commission believed that the gap resulted from a decline in the growth of the Swedish economy, a growing elderly population that needs much health care, expanding but expensive capacities for diagnosing and treating disease, and social changes that make it harder to turn to the traditional nuclear family to provide care and support [6]. The Swedish diagnosis of the problem is about the same as that proffered by American analysts [1-4, 7]. The prescribed treatment, however, is different in Stockholm than it was or is in Washington.

The Priorities Commission, consisting of six public officials assisted by a group of physicians, hospital administrators, and professors, looked at what other developed nations were doing to cope with the growing gap between need and resources. They also surveyed and held hearings with health care providers, patient groups, and pensioners and met with various professional and government bodies. The resulting report shows an unflagging belief that government has the key role to play in setting explicit priorities. Placing the responsibility for rationing on the government reflects the fact that, in Sweden, county councils and municipalities provide 75% of all revenues for health care through taxes. The national government has the power to shape local tax policies, impose mandates on medical training and research, and set priorities for public health. In Sweden, there seems to be little doubt that government has the leverage it needs to be taken seriously as the locus for health reform and that government is responsible for setting priorities in health care when choices must be made.

The Commission's final report is relatively short, only 132 single-spaced pages. And, although ethical and philosophic commentators make cameo appearances at various places, the tone of the findings indicates that they represent a political consensus rooted in a common cultural and moral outlook more than a product of pioneering moral theorizing. Especially noteworthy is that, although the Priorities Commission report has plenty to say about implementing priorities, the report's novelty and strength lie in its effort to establish ethical principles for guiding what should not be done.

The Commission maintains that any scheme for prioritizing must accept three core principles: that all human beings are equally valuable; that society must pay special attention to the needs of the weakest and most vulnerable; and that, other things being equal, cost-efficiency and gaining the greatest return for the amount of money spent must prevail. These simple principles have serious and important consequences for policy.

The commitment to the core values of human dignity, solidarity, and efficiency [6] leads almost immediately to the exclusion of certain prioritization strategies purely on moral grounds. Plans that would bridge the gap between need and resource availability by throwing the poor, the elderly, the sinful, or the prematurely born into the gap to close it are simply unacceptable. Solutions that permit the wealthy, the socially prominent, or those who hold positions of power to walk across the gap on their wallets are also dismissed as morally unacceptable. The Swedes basically argue that priorities should be set (and there is no indication in this report that anyone thinks they do not have to be set, and soon) in a way that treats everyone as a moral equal, that does not pick on any single vulnerable or frail group, and that takes cost-efficiency seriously. This may not seem like much, but if these simple moral rules are accepted, in both Sweden and the United States, their effect would be an enormous boon to health policy.

In a fairly long chapter, the Swedish Commission reviews the efforts of other nations to grapple with the problem of setting priorities in response to gaps between need and resources. The efforts in Holland and Norway [8] to establish a set of priorities for their health care system, although relatively unknown and unmentioned in discussions of rationing in the U.S., are discussed with some justly deserved favorable comments. The other attempt that receives attention is Oregon's widely noted effort to set priorities in its health care system by limiting benefits coverage in the state's Medicaid program, thereby freeing more funds for the uninsured [9]. The Commission lauds Oregon's courage in pioneering an effort to establish priorities that are based on the efficacy and effect of treatments, but it says little more about the plan.

To me, this seems exactly right. If the simple moral principles that the Swedes advanced as limits on any attempt at rationing are applied to the Oregon effort, then that effort is called into question. Oregon has led the way in trying to emphasize the importance of cost-efficiency in setting priorities in health care. Although it is possible to quibble about Oregon's methods and data, letting people have insurance and increasing their access to primary care do seem to save money without compromising health [10]. However, social solidarity is not much on display when only the poor are the object of setting priorities. And there is room for doubt about the degree to which the Oregon process reflects a commitment to taking the needs of vulnerable groups such as the disabled, the prematurely born, and children as seriously as it should [9, 11].

From U.S. perspective, the Swedes seem to be in a rush to set priorities for everyone without asking tough questions about whether rationing could be delayed or where the fat in their system might be. From a Swedish perspective, at least as captured in the Commission's report, Americans seem willing to talk endlessly about anything with respect to their health care system except the need to set priorities in a way that might affect every citizen. The Swedes have done an important service by noting that ethics must be an essential component of any debate about priorities or rationing in health care—not because there is consensus about what is right when it comes to rationing, but because there must be consensus about what is wrong [11, 12].

• Copyright ©2004 by the American College of Physicians