Patient empowerment

Covert rationing depends on a credulous public, and on well-behaved patients. Maintaining Quadrant III healthcare requires the general public to ignore the necessity and the reality of rationing, and to believe that any apparent limits on healthcare result from corruption, waste, and inefficiency, which, thanks to the efforts of Wonkonians and Gekkonians, are being rooted out bit by bit. More important, when members of the general public become patients themselves, covert rationing requires them to rely on their doctors and their health plans to determine what's right for them.

This requirement is the Achilles' heel of covert rationing. For once you become a patient, behaving as you're supposed to produces an immediate threat to your own life and limb. In other words, continued covert rationing requires that patients continue to act in a manner that is against their own interests.

Patients who understand this-who understand that it is not in their interest to rely on the advice of their doctors and health plans-can take immediate steps to protect themselves. Instead of passively accepting the diagnoses and recommendations for treatment that are presented to them, these patients will check things out for themselves and seek independent confirmation that nothing is being overlooked or "forgotten." They can make it hard for the healthcare system to practice covert rationing against them.

If enough patients do this, the covert rationing of healthcare will no longer be possible. Covert rationing will collapse under its own weight, from within, because of the actions of tens of thousands of individuals acting independently in their own interest. Covert rationing simply will not work any more.

The collapse of our Quadrant III healthcare system will be painful. When it occurs, our healthcare system is likely to become even more chaotic for a time than it is today. Yet it is at this point that we will be forced to face the real limitations to what our healthcare system can provide. Americans will at last be ready to hear the truth. Some brave leader can show us what our real choices are, without being stoned, banished, or ignored. And finally we can begin constructing a new, rational, and equitable healthcare system.

At this moment, when Gekkonian covert rationing collapses under the weight of patients behaving badly (that is, autonomously), Wonkonians will immediately step forward with their solution-a centrally controlled Canadian-style healthcare system. But they will find that Americans are even less ready for such a system than they were in 1994.

Here's why: Covert rationing will not have failed because it wore everybody down to the point where anything seemed better. Instead, it will have failed because of a new multitude of self-empowered Americans. The American populace will fit even less than it does today the profile necessary to establish a paternalistic, top-down, government-run healthcare system. Whatever system we establish at that point to replace covert rationing, whether or not it resembles the system we discussed in the last chapters, it will have to honor the self-actualized, self-empowered, autonomous American patient.

The catalyst to a uniquely American solution to the problem of healthcare rationing, then, is the empowered patient. Americans-not all Americans, not necessarily a majority of Americans, but a critical mass of Americans-are going to have to begin taking their healthcare into their own hands. For this to become possible, a sufficient number of doctors have to recognize that empowered patients are their best hope for salvaging their profession, and they have to support those patients. And the American biomedical industry has to understand that their own survival depends on helping individual patients become self-empowered.