Covert rationing and what it means 

In the United States, we have placed our government and our managed care organizations into an in intractable dilemma, from which their only possible response is to conduct covert healthcare rationing.

First, we have told them to figure out how to create centralized pools of money from which to pay the cost of all of our healthcare. Such an arrangement stems from the reality that medical care, for almost anyone who really gets sick, has been priced out of reach. For even a substantial proportion of our citizens to receive top-notch healthcare, we must have general cost-sharing mechanisms in place.

Stated another way, healthcare has become a de facto entitlement in the United States. I make no claim that it is a well-functioning entitlement. (How could it be when millions of taxpayers who contribute to the centralized money pools are not themselves covered?)  Nonetheless, we all expect and demand that some kind of centralized funding mechanism (whether public or private) be in place so that every deserving ("deserving" being defined in different ways) American resident is well-covered, and we often express outrage that our leaders have yet to figure out how to do this.

While we insist that our leaders treat healthcare an entitlement (which, as we have just seen, requires rationing), at the same time we insist they adhere to another fundamental imperative, this one precluding rationing. That imperative is the "the culture of no limits." Unlike the entitlement mentality - which is nearly universal in Western countries - our deeply-held culture of no limits is uniquely American.  The culture of no limits can be stated thusly:

In America we have and will continue to have the best healthcare in the world, the best doctors, the best hospitals, and the best technology. Since one cannot place a price on human life, everything that can be done for a sick person must be done, as long as there is some small hope of a beneficial outcome. Finally, every disease is potentially curable, and as a matter of policy we will strive to learn how to cure every disease, death itself being merely a manifestation of insufficient technology. In summary, where healthcare is concerned there are and can be no limits.

So, at the same time we find ourselves up against inherent spending limitations that require rationing, we find that there can be no limits.

We can see right away that these two fundamental tenets - the entitlement mentality and the culture of no limits - are in their essence completely incompatible with one another.  And our need to simultaneously hold onto these two incompatible but necessary imperatives has strongly driven our healthcare system toward a policy of covert rationing. 

Covert rationing is our only option, since we must ration but cannot admit it.  But covert rationing is a completely dysfunctional way to run a healthcare system.  It places patients in mortal danger, destroys the fabric of the medical profession, and undermines the integrity of American society itself. In fact, covert rationing ultimately explains all the seeming chaos and illogic that are inherent in today's healthcare system.

Is covert rationing a vast conspiracy?

On the surface it might seem impossible to conduct widespread rationing in a huge industry like healthcare, which consumes nearly 15% of the GDP and directly affects the lives of most of us at one time or another, and to do it covertly, in secret.  Wouldn't the rationing of such a highly visible commodity be apparent to everybody?  

Actually, it is quite apparent if you look for it.  It's just that we've all more-or-less agreed not to look.  Indeed, covert rationing is not a conspiracy being foisted on millions of innocent Americans by a vast and evil cabal. As we are about to see, much of the rationing activity is only poorly hidden, and its covert nature must rely on an almost willful failure of the "innocents" to recognize it for what it is. Furthermore, the individuals who are actually conducting the rationing - the doctors, the hospital administrators, the managed care and insurance executives, the scientists, the policymakers and regulators - for the most part subscribe to the same "no limits" mentality as everyone else. Most would probably find the notion of rationing healthcare to be repugnant, and would probably take offense if they should hear they are being accused of it.

The covert rationing of healthcare is, in fact, a textbook case of subconscious collusion. Subconscious collusion is a defensive mechanism invoked by any social order when that social order is faced with an unpleasant fact of life that is a) unavoidable, and b) unacceptable. It is an unspoken, often subliminal decision to coexist with the unacceptable fact of life, but not to notice it, acknowledge it, or confront it.  Consider the wife who subliminally decides not to notice that her husband is having a string of extramarital affairs.  And consider the German populace during World War II, apparently failing to notice the holocaust.  Subconscious collusion is a relatively common survival technique that allows a social order to persist, for a time, when some fundamental tenet of that order has become severely compromised.  The major problem with subconscious collusion is that it allows the root problem to grow unchecked - and by definition, unnoticed - until the social order being "protected" implodes.  

In the case of healthcare rationing, subconscious collusion operates thusly: First, the irresistible economic forces that require rationing and the irresistible social forces that forbid rationing line up to foster a certain attitude, a certain way of looking at things. Then, within every entity operating within the healthcare system, those who embrace such an attitude become ascendant, not by conspiracy or plot, but by natural market forces.

That certain correct attitude, the new "right stuff," is defined by the ability to suggest actions that have the effect of limiting healthcare services, while couching those suggestions in the language of the culture of no limits. In essence, this kind of thinking allows organizations to direct the rationing of healthcare, while at the same time advancing the notion that rationing is unnecessary.

It is important to understand that there is surprisingly little hypocrisy under this scenario. While undoubtedly some of the individuals who are directing the rationing behavior understand exactly what they are doing, most genuinely continue to subscribe to the myth of "no limits."  Most honestly believe (or at least, want very badly to believe) that their actions are not reducing useful services, that instead, they are reducing waste and improving the efficiency of the system.  Those who do understand the true nature of their actions generally shield themselves from having to communicate that knowledge.  They are more likely to become the quiet, private CEO's or Board Directors whose spokespersons and PR specialists (individuals who are entirely sincere about what they are telling the public) do their speaking for them.

So there is no conspiracy.  The covert rationing of healthcare is conducted by a myriad of organizations, all acting quite independently, and all simply responding to economic and social imperatives.  The key for organizations that want to flourish within our healthcare system, then, is to identify leaders who can respond both to the irresistible need to ration healthcare, and to the equally irresistible need to rationalize such behavior in terms acceptable to the rest of us.  Those individuals, men and women of vision, are the Most Valuable Players in American healthcare.

The enabling visions advanced by such individuals - visions that permit covert rationing activities to go forward openly, freely, and often profitably - can be categorized into two general schools of thought.  We will be spending some time with both schools of thought, and will be getting to know them well.  A brief introduction for now will suffice.