When is rationing not rationing, a mandate not a mandate and price-fixing not price fixing?
When the government says so.
Supporters of the ACA react to the opposition’s charges of rationing by pointing out that the law expressly forbids it: “[Cost-reduction proposals] shall not include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums…increase Medicare beneficiary costsharing…or otherwise restrict benefits...” (Pub. L. 111-148, § 3403)
But if the government takes your money to fund Medicare and then in any way limits your access to the benefits of that program, that's rationing. Since in addition to rationing the law also prohibits benefit restriction and increased cost sharing, the only effective way left to achieve mandatory spending cuts is to lower payments to doctors and hospitals. If you end up with less access to medical care because the government pays less, that’s rationing. No matter how much you deny it, or what you call it, a rose is a rose...and government restricted access to health care is rationing.
The same people who say the ACA will not ration will also tell you that markets ration through prices. This is an erroneous portrayal of the role of prices in a free market. Free market prices are simply a signal. Prices do not ration any more than a bathroom scale makes you fat or thin. Free market prices reflect the relative scarcity of resources and then allow you to decide how to allocate your own private resources. Free market prices are what people voluntarily pay; government rationing is an act of force. It's a fundamentally different kind of interaction when the government forcibly determines how your resources must be allocated—either by expropriating them first, as in the case of Medicare, or by mandating how you must spend them, as in the case of the individual mandate to purchase health insurance.
Speaking of mandates—in the legal challenges to the ACA, the U.S. Solicitor General argues that the law’s “requirement to maintain minimal essential coverage” is not a mandate to buy coverage; it just regulates how we pay for health care. This is a distinction without a difference. Lawyers are adept at word games, but if you look at the actual effect of the law, it’s a mandate which offers no real choice: either you obtain a government-defined product or you break the law and pay a penalty.
Just over a year ago, the Christian Science Monitor reported on an antitrust case by the Department of Justice against Idaho orthopedists who, in refusing to accept government price controls, were found guilty of “price fixing.” The DOJ hubristically declared, “Government prices are market prices.” In this Orwellian move, the government declared voluntary prices to be price-fixing, and government-determined prices to be market prices. Anyone with common sense can see that changing terminology does not change reality.
In yet another attempt to command reality, the new heath care law forbids the use of quality-adjusted-life-years (QALYs) as a means “to establish what type of health care is cost-effective.” But as pointed out by Neumann and Weinstein in the New England Journal of Medicine, QALYs are the yardstick currently used in thousands of cost-utility studies to compare outcomes and determine cost-effectiveness. It is hard to imagine how this ban could be any more meaningful than the ban on rationing discussed above.
Other misrepresentations include pretending that compelling doctors to follow clinical guidelines (or risk nonpayment) isn’t “cookbook medicine.” Or, that these guidelines are “evidence-based care” when much of the “evidence” is controversial and many of the guidelines are written or funded by entities vested in a particular outcome. Or, that government “energy efficiency” standards don’t ban incandescent light bulbs, but instead only impose legal requirements that the bulbs fail to meet.
As Richard Ralston of Americans for Free Choice in Medicine warns, “When the clear meaning of words is replaced with government fiat in this way, all limits on arbitrary government power and its use of force are destroyed.”
“Rationing,” “mandate,” and “price-fixing” are all terms with precise meanings in plain English. Shame on us if we are fooled by the deliberate distortion of these simple definitions. Stick and stones can break our bones, but words can actually hurt us --when they are used to obscure instead of clarify our understanding of reality.
Beth Haynes, MD, Founder and President of TheBlackRibbonProject.org for health care freedom and the doctor-patient relationship; Senior Health Care Policy Analyst, Docs 4 Patient Care; formerly board certified in Emergency Medicine and Family Practice.