Rationing or Tough Choices?

Last summer, Sarah Palin made headlines and ignited the fury of tea partiers in town hall meetings across America when she accused President Obama of trying to establish "death panels" as part of the health care reform bill moving through Congress. The provision of the bill in question—eventually abandoned because of the controversy—would have reimbursed physicians once every five years for counseling patients about advance health care planning (living wills, health care powers of attorney, hospice, palliative care, etc.). Palin's mischaracterization of the bill was criticized by many as the most underhanded ploy in the intense fight over health care reform; it was judged by Politifact.com as the biggest political lie of 2009. Here's the exact language Palin posted on her Facebook page, thus sparking the controversy:

"The Democrats promise that a government health care system will reduce the cost of health care, but as the economist Thomas Sowell has pointed out, government health care will not reduce the cost; it will simply refuse to pay the cost. And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's "death panel" so his bureaucrats can decide, based on a subjective judgment of their "level of productivity in society," whether they are worthy of health care. Such a system is downright evil."

Palin pointed her finger at Obama, and she implied her own party would never tolerate an America where death panels rationed care. I wonder why she hasn't pointed her finger at the Arizona State Legislature. What am I talking about? The Arizona State Legislature's recent decision to ration transplant care.


The Arizona Legislature is controlled by a Republican majority, and after last year's dust-up over death panels it's no wonder the Arizona budget cut was characterized as "a tough choice" instead of "rationing." In political speak, regardless of party, rationing is bad and tough choices are courageous. When we compare Sarah Palin's comment with the actions taken by the Arizona Legislature, the new rule of health care budget cuts can best be expressed this way: it's "rationing" when the other party does it, but it's a "tough choice" when our party does it.

Is there no sanity left among our political leaders? It should be obvious by now to any thinking person that our nation cannot afford to give everything to everybody. Leaders who make difficult decisions to invest scarce resources where they will do the most good are not evil, they are realists. But allocating scarce resources according to where they will do the most good is politically treacherous.

When Dr. John Kitzhaber was Governor of Oregon in the late 1980s, he tried to prioritize Medicaid resources in order of value but his plan was decried as rationing and disallowed by CMS under President George H. W. Bush. "The proposal was finally approved in 1993 by President Bill Clinton's administration, and the concerns about rationing generally subsided as Oregon's plan ended up providing fairly substantial benefits to Medicaid recipients. In addition, the state added thousands of new recipients, reducing the rate of uninsured residents from 18 percent in 1992 to 11 percent in 1996, according to a study in the journal Health Affairs." Kaiser Health News, October 2009.

Years later, when President Obama's plan sought to reimburse physicians for much-needed end-of-life planning, Sarah Palin ignited a firestorm by labeling the Democrats as rationers.

In these high profile examples, the Democrats proclaimed themselves as leaders who were ready to make tough choices about resource allocation, and the Republicans benefitted politically by taking a stand against rationing. So what changed in Arizona that led a GOP-controlled legislature to ration transplant care? The cold hard reality that Arizona cannot afford to cover everything. Truth is no other state can either. Whether we call it "rationing" or "making the tough choices," it's ironic that Republicans in Arizona and in many other states (including our own) will now have to make the hard decisions for which they so loudly criticized their Democratic rivals last year.

Maybe, just maybe, our elected leaders will get past the campaign rhetoric and finally have a level-headed conversation about which services our nation can afford to provide to every citizen. As hospital leaders, we'd better hope so. As long as our leaders avoid the debate, hospitals will be expected to solve society's problem in their emergency rooms.