Rationing of healthcare before, during and after COVID-19

Early in the COVID-19 pandemic, it became evident the United States would face difficult resource allocation decisions. Projected shortages of ventilators and beds in hospital intensive care units prompted frameworks for rationing scarce healthcare resources during a public health emergency. These frameworks incorporated several guiding ethical values. Yet, none suggested rationing based on an individual’s ability to pay for care.

In the pandemic context, there is widespread agreement that the ability to pay is not an ethically appropriate way to determine who receives care. But, what about under normal circumstances?

Acute instances in which demand exceeds a finite supply of a product, such as a ventilator, certainly call for a specialized response. However, while rationing decisions might not always be as stark as the expected ventilator shortage, they consistently occur. Rationing occurs in every healthcare system, including in the United States.

All resources are scarce. This concept is built into common definitions of the subject of economics. The nation’s healthcare resources must be allocated among patients in need according to either explicit or implicit criteria.

The rationing frameworks espoused during the pandemic demonstrate some of the various ways in which healthcare can be, and is, rationed by healthcare systems in other countries, including consideration of life-years saved and wait times.

In the United States, de facto rationing generally occurs through prices according to the ability to pay. Approximately one-third of U.S. adults report skipping needed care or treatments because of cost.

This implicit rationing gives some people the impression that rationing of healthcare does not take place in the United States. Use of the term rationing commonly evokes notions of “death panels.” Debate about healthcare rationing has a long and storied history in both medical ethics and health economics literatures.

Health economists have proposed certain mechanisms to contain growth of healthcare spending overall and as a way to make decisions about which services and treatments should be covered in programs with relatively fixed budgets, such as Medicare and Medicaid.

Because the idea of rationing runs counter to Americans’ beliefs in the principles of free market economics, the notion that a policy proposal will enable the government to ration care tends to spark public backlash.

For example, such political rhetoric and accompanying public backlash have pervaded discussion of Oregon Health Plan’s use of funding priorities in Medicaid and contributed to the demise of the Independent Payment Advisory Board created by the Affordable Care Act.

The recently re-enlivened discussion about ethics of rationing should prompt conversation about whether there is something specific about crisis standards of care and rebuke of the use of a price mechanism to allocate care. Are the ethical values that guide access to healthcare resources distinct under emergency conditions? Or should the same values consistently guide access and delivery under routine circumstances?

Although rationing carries a highly negative connotation, people are better able to accept that it must happen during an emergency. More broadly though, the COVID-19 crisis is a reminder that the need to ration resources is ever-present in healthcare. This pandemic will generate a lot of lessons learned, which as history suggests, will have varying degrees of influence on actual policy responses.

The experience of developing ethical frameworks to guide resource allocation decisions during a shortage, coupled with increased public awareness of the need to make such decisions, should spur us to revisit the discussion of healthcare rationing on a larger scale in the post-pandemic era.

Rationing schemes reflect social values. There are, as recent ethical analysis outlines, more and less ethical ways to do it. When the emergency has ended, neglecting to examine how the United States currently rations access to medical care writ large would be a missed opportunity.

-By Hadley Stevens Smith, Ph.D., MPSA, Health Policy Fellow, Center for Medical Ethics and Health Policy, Baylor College of Medicine

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