Having A Rational Discussion About Rationing Is So Hard These Days


We’re going to tie in two Bloggingheads founders in one post.

Mickey Kaus:

From out here on the West Coast, it sure looks as if OMB Director Peter Orszag is the Donald Rumsfeld of the looming health care quagmire, in the sense that a) it’s his strategy that’s failing–at least failing to win over public opinion; and b) it’s hard to see how the strategy changes with him in the position he’s in, and c) he’s a logical fall guy in any case. … What did he do wrong? His insistence on–and insistence on talking about–long-term cost-bending successfully scared off a large segment of the American electorate by raising the issue of rationing. Hearts and minds. And it was all unnecessary, if (as he claims) health care reform can be deficit neutral over the next ten years without the curve bending. If the curve can be bent it can be bent later. Or at least more quietly …

Mickey Kaus also thinks Palin has a point. He links to this piece by William Jacobson at Legal Insurrection:

These critics, however, didn’t take the time to find out to what Palin was referring when she used the term “level of productivity in society” as being the basis for determining access to medical care. If the critics, who hold themselves in the highest of intellectual esteem, had bothered to do something other than react, they would have realized that the approach to health care to which Palin was referring was none other than that espoused by key Obama health care adviser Dr. Ezekial Emanuel (brother of Chief of Staff Rahm Emanuel).

The article in which Dr. Emanuel puts forth his approach is “Principles for Allocation of Scarce Medical Interventions,” published on January 31, 2009. A full copy is embedded below. Read it, particularly the section beginning at page 6 of the embed (page 428 in the original) at which Dr. Emanuel sets forth the principles of “The Complete Lives System.”

While Emanuel does not use the term “death panel,” Palin put that term in quotation marks to signify the concept of medical decisions based on the perceived societal worth of an individual, not literally a “death panel.” And in so doing, Palin was true to Dr. Emanuel’s concept of a system which

“considers prognosis, since its aim is to achieve complete lives. A young person with a poor prognosis has had a few life-years but lacks the potential to live a complete life. Considering prognosis forestalls the concern the disproportionately large amounts of resources will be directed to young people with poor prognoses. When the worst-off can benefit only slightly while better-off people could benefit greatly, allocating to the better-off is often justifiable….When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most chance, whereas the youngest and oldest people get chances that are attenuated.”

Put together the concepts of prognosis and age, and Dr. Emanuel’s proposal reasonably could be construed as advocating the withholding of some level of medical treatment (probably not basic care, but likely expensive advanced care) to a baby born with Down Syndrome. You may not like this implication, but it is Dr. Emanuel’s implication not Palin’s.

Michael Crowley at TNR (entire post):

Arguing (cheekily, one hopes) that “Palin had a point,” Mickey links to this guy, a Cornell Law Professor named William Jacobson, who offers an embarassingly lame defense of Sarah Palin’s use of the phrase “death panel,” in quotation marks, in her Facebook attack on Obama’s health care plan. Quoth the legal scholar:

“Palin put that term in quotation marks to signify the concept of medical decisions based on the perceived societal worth of an individual, not literally a “death panel.””

Oh! Not literally a death panel! Funny how some people misunderstand quotation marks as indicating precision and literalism. So, when I write that William Jacobson is in favor of a new “greedy insurance industry price-gouging scheme,” people should understand the nuanced concept signified therein.

P.S. Jacobson doesn’t even bother trying to defend the other phrase Palin puts into misleading quotation marks–“level of productivity in society”–which as far as I can tell has no connection to any proposal authored or even imagined by any Democrat currently in a position of power. Presumably that’s another concept the currently-unemployed Palin didn’t have time to spell out.

Eugene Robinson at WaPo, via Robert Wright at Sully’s place:

[…] reform is being sold not just as a moral obligation but also as a way to control rising health-care costs. That should have been a separate discussion. It is not illogical for skeptics to suspect that if millions of people are going to be newly covered by health insurance, either costs are going to skyrocket or services are going to be curtailed.

The unvarnished truth is that services are ultimately going to have to be curtailed regardless of what happens with reform. We perform more expensive tests, questionable surgeries and high-tech diagnostic scans than we can afford. We spend unsustainable amounts of money on patients during the final year of life.

Yes, it’s true that doctors order some questionable procedures defensively, to keep from getting sued. But it’s a cop-out to blame the doctors or the tort lawyers. We’re the ones who demand these tests, scans and surgeries. And why not? If a technology exists that can prolong life or improve its quality, even for a few weeks or months, why shouldn’t we want it?

That’s the reason people are so frightened and enraged about the proposed measure that would allow Medicare to pay for end-of-life counseling. If the government says it has to control health-care costs and then offers to pay doctors to give advice about hospice care, citizens are not delusional to conclude that the goal is to reduce end-of-life spending. It’s irresponsible for politicians, such as Sarah Palin, to claim — outlandishly and falsely — that there’s going to be some kind of “death panel” to decide when to pull the plug on Aunt Sylvia. But it’s understandable why people might associate the phrase “health-care reform” with limiting their choices during Aunt Sylvia’s final days.


Mickey Kaus has been pushing this meme for awhile, but I guess now that it’s moved from the Slate-blog part of the Washington Post empire to the newpspaper-op-ed part, we should take it seriously. It may give too little credit to the ruthlessly efficient messaging machines of the Republican party and the health-care industry. I don’t think Obama had to dwell long or loudly on cost containment for them to sense and exploit its perverse political potential. (And, on a similarly cynical note, I don’t think it matters much, politically speaking, whether Jon Cohn is right in saying that Obama’s plan would indeed control costs.)

I certainly agree that Obama’s emphasis should have been more on the immediate personal benefits of reliable health coverage and less on distant, collective fiscal benefits. I’m just not sure this would have saved us from Sarah Palin’s death panels.

More Wright:

In Palin’s fantasy, the death-panel “bureaucrats” were going to pick winners and losers based on a judgment about their “level of productivity in society.” Well, if you view income as a gauge of a person’s productivity in society—and God knows there are Republicans who do—then the quality of health care is already correlated with “productivity in society.” Obama’s plan, by making health care more affordable to lower income people, would make that less true.

This is just another way of making a point already made by Peter Singer in response to less delusional concerns about the possibility of rationing under Obama’s plan: we already ration health care; we just let the market do the rationing.

Any government health care plan will bring some new form of “rationing,” since no government can afford to guarantee everyone all possible medical treatment. But let’s be clear: the people who are trying to sabotage reform by telling mind-boggling lies about its hidden rationing agenda seem, in fact, pretty content with rationing; they seem happy with a system in which the least “productive” members of society get bad health care, including, occasionally, health care so bad that it leads to death.

Megan McArdle:

But there is also a real difference between having something rationed by a process and having it rationed by a person. That is, in fact, why progressives are so fond of rules. They don’t want to tell grandma to take morphine instead of getting a pacemaker. It’s much nicer if you create a mathematical formula that makes some doctor tell grandma to take morphine instead of getting a pacemaker. Then the doctor can disclaim responsibility too, because after all, no one really has any agency here–we’re all just in the grips of an impersonal force.

But this won’t do. If you design a formula to deny granny a pacemaker, knowing that this is the intent of the formula, then you’ve killed granny just as surely as if you’d ordered the doctor to do it directly. That’s the intuition behind the conservative resistance to switching from price rationing to fiat rationing. Using the government’s coercive power to decide the price of something, or who ought to get it, is qualitatively different from the same outcome arising out of voluntary actions in the marketplace. Even if you don’t share the value judgement, it’s not irrational, except in the sense that all human decisions have an element of intuition and emotion baked into them.


Also, the market doesn’t deny you a hip replacement or a pacemaker because someone in government thinks your political views are “un-American.” Given the cronyism and thuggery we’ve seen with the bailouts, etc., I’m not confident this would hold true under a government health program. And I’m absolutely certain there would be a special track for insiders and favorites.

John Holbo:

She has apparently mistaken concern about an underfunded public mandate for a public mandate of private underfunding and sort of mashed them together in her mind. That is, she thinks the government will drive doctors to sell shoddy aspirin and at the same time (very likely? surely?) forbid the sale of better aspirin on the private market. But where the hell is that second bit coming from? Unless I’m missing something, it’s as crazy as the ‘killing old people’ alarmism, because it’s just as divorced from any potential motive lawmakers might have. What possible motive could legislators have to force people not to top up their own healthcare on the private market to the degree that they deem prudent? What would be in it for the legislators, even the most Machiavellian of them? “If you design a formula to deny granny a pacemaker, knowing that this is the intent of the formula …” Now here McArdle has to be talking, not just about a formula that omits to promise granny a pacemaker, but a formula that positively forbids it to her – removes it from the market. Gives her a ration book without a pacemaker ticket. And says only ration book tickets may purchase health care items. McArdle might come back and say she actually meant the other thing, that some piece of legislation might merely not promise a pacemaker. But hell, most legislation doesn’t do that. Practically everything congress has ever done doesn’t give granny a pacemaker (usually because it isn’t about healthcare at all). We don’t say it follows that almost all acts of congress are attempts to ration pacemakers. That’s a crazy way to use the word ‘ration’.

And yet here is Megan McArdle, complaining about people overusing the word ‘ration’. It’s a funny old world, I say.

Conn Carroll

Matt Yglesias

UPDATE: More Kaus

UPDATE #2: More Holbo. McArdle responds. Holbo responds.


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