Health care rationing has been a source of contentious debate in the United States for nearly 30 years. Because rationing is bewildering to many Americans, persistent myths about "death panels" and critical health care decisions to be made by faceless bureaucrats abound, instilling fear about health care reform and cost containment measures aimed at slowing spending growth. This paper retrospectively reviews the policy literature on health care rationing over the past quarter century, examines alternative definitions and classification schemes, traces the evolution of the debate, and explores ways in which rationing may be made more rational, transparent, and equitable in the future allocation of scarce health care resources.
It has been almost three decades since Henry Aaron's and William Schwartz's 1984 book, The Painful Prescription: Rationing Hospital Care, touched off a policy debate over the need to employ stern measures to bring rising health care costs under control. Since then, the debate over health care rationing has been confined mostly to the pages of academic journals. In 2009, however, it erupted violently in newspaper headlines across America when Sarah Palin and others charged that proposed end-of-life counseling for Medicare beneficiaries constituted "death panels" that would ration care and decide the fate of elderly Americans (Saltonstall 2009; Rutenberg and Calmes 2009). Although these false claims were quickly challenged (Allen 2009; Blumenauer 2009; Bookman 2009; Diaz 2009; Farley 2009; Parker 2009), such counter measures often fail (Nyhan and Reifler 2010), and in this case, the myth of death panels persisted and became so pervasive (Holan 2009) that it instilled fear about health care reform and triggered an unfortunate retreat from advanced care planning (Tinetti 2012). Hyperbolic claims of "rationing" and "death panels" subsequently were used as weapons at different times (and with varying effect) to: oppose the appointment of Donald Berwick as administrator of the Centers for Medicare and Medicaid Services; disparage the Food and Drug Administration's decision to withdraw the breast cancer drug Avastin from the market; and bludgeon the Independent Payment Advisory Board (IPAB), whose mission under the health reform law is to rein in Medicare spending that exceeds pre-set limits (Arkansas Democrat-Gazette 2011; Cohn 2011; Ferrer 2011; New York Times 2012; Nocera 2011; Ornstein 2011; USA Today 2011).
What is it about rationing of care that evokes such heated, visceral reaction? Perhaps it strikes a nerve in individuals who legitimately fear that rationing schemes will limit their access to health care. More likely, the concept of "rationing" bewilders many people, leading to the mistaken belief that it exists only in other countries. Whatever their source of discomfort, Americans respond negatively to the slightest mention of the word. Capitalizing on these misconceptions and fears, reform opponents routinely invoke the specter of rationing to discredit various provisions of the Patient Protection and Affordable Care Act (ACA) and to distract the public from the law's true aims. Ironically, the Medicare budget plan proposed by Rep. Paul Ryan and supported by many ACA critics has been cited by the Congressional Budget Office as likely to produce the very kind of rationing that reform foes claim to detest (Rovner 2011).
Twenty-five years ago, the late Jeff Merrill and I wrote a guest editorial in Inquiry that tried to dispel myths about rationing in U.S. health care (Merrill and Cohen 1987). We argued that our health care system always had rationed care based on price and ability to pay and that these mechanisms, together with the indirect effects of several cost containment policies (e.g., certificate-of-need regulation and chronically low Medicaid payment rates to providers), had conspired to limit access to care for vulnerable segments of the population. …