Government does, indeed, ration health care.

Doctors make decisions based on the good of the individual. When it comes to health care states must make policy based on what is good for the whole population.

The largest purchase the average American family will make in their lifetime is no longer their house, but their health care. Over the last 30 years, health care also has been the fastest growing part of the average state, federal, corporate and household budget. National spending on health care averages close to $4,000 per person, more than the per capita earnings of over half the people in the world.

Taxpayers now fund approximately 50 percent of the $1 trillion cost of the American health care system. The funding comes through Medicare and Medicaid, plus state and federal funding of medical schools, public health, employee benefits, etc. One dollar out of every $7 spent in America is for health care.

Yet for all our spending, we still have approximately 43 million Americans without health insurance, and the state of our health is not equal to many other developed countries. Surprisingly, we have spent little time discussing the government's role in health care or what we get for our money. What should a state's role and goal be in funding health care? How do we hold the system accountable for public dollars? Who should the state cover and for what benefits?

PUBLIC POLICY VS. PROVIDERS

Policymakers have not done enough to assert the broader public interest in achieving a healthy state or nation. The public policy of a nation cannot be judged solely by the quality of its medicine or driven simply by the ethics of health providers. Medicine is a key part, but not the only part, of a health care system. Policymakers mostly fund health providers to deliver all "reasonable and necessary" care to covered categories of citizens, and we ask few questions about what is delivered or if we have a just system.

We leave large numbers of medically indigent without health insurance, yet we tell ourselves proudly that we don't "ration" medicine. But every state "rations" taxpayers' money in a process called budgeting. Whenever demand for tax dollars exceeds the supply of those dollars (which is always), a state prioritizes and "rations" the money and services it buys. A state must ask not "if" it rations, but "how."

A state's role and obligations in the health area vary considerably from the role and obligations of health providers. Consider that policymakers view the big picture while providers consider the individual patient: policymakers always consider cost, providers believe cost is not a consideration; policymakers try to maximize good while providers must "do no harm."

Doctors and other medical providers are patient advocates and don't have to deny needed care, but public policymakers' moral universe is not the individual, but all citizens. As Oregon Governor John Kitzhaber, a physician, maintains, "The legislature is clearly accountable not just for what is funded in the health care budget, but also for what is not funded. Accountability is inescapable ..."

Whoever pays for health care rations medicine. An insurance contract is a rationing document in that it limits what is covered and not covered (tattoo removal? Viagra? bone marrow transplants?) and who is eligible for reimbursement (naturopaths? chiropractors?). Rationing is inherent every time we make up a budget.

INFINITE NEEDS, FINITE RESOURCES

Are health professionals in the best position to judge how to keep a state healthy? Clearly they are not. One thoughtful observer points out why this is so:

"Professionals tend to believe that they are the only ones able to make informed choices. In fact, many of them are not trained to see the overall health situation of the whole population, but only the problems of the individual patients. The devotion of the physician to her patient may make it difficult for her not to seek an excessive share of the available resources and to overlook the resulting loss to other patients," says E.O. Attinger, an official with the World Health Organization.

Health providers, as patient advocates, understandably have difficulty looking at the social context of disease. They are experts in the human body and disease, but not necessarily in health policy. Government must look at the social context of all problems and decide how to allocate limited funds to buy the most health for those it covers. Doctors can say yes without saying no. In public policy, everything we do prevents us from doing something else. Government can't meet the Hippocratic oath's standard of "do no harm," it must maximize good with always limited money.

As Victor Fuchs has wisely observed, paraphrasing Abraham Lincoln, "A nation can provide all of its people with some of the care that might do them good; it can provide some of its people with all of the care that might do them some good, but it cannot provide all of its people with all of the care that might do them some good."

How do we decide who is covered for what?

ASKING THE HARD QUESTIONS

Ethical health policy must not be the sum total of all individual citizens' "beneficial" medicine. Government could never underwrite the open-ended commitment for reimbursement for every service that the doctor and patient thought "beneficial" to an individual patient. Public policy today has no way to weigh and balance health care spending either within the health care system or against other important priorities.

My generation of public policymakers did not ask enough hard questions of the health care system. We lacked proportion and allowed health care spending to grow out of control. Consequently, we have today many badly maintained public buildings, yet approximately half the hospital beds in America are empty. We have too many doctors (unevenly distributed) and too few teachers. Most American cities have duplicative and redundant medical technology near schools that are without computers for students. We keep people alive in a permanent vegetative state in cities where 20 percent of the population are uninsured, and many kids don't have vaccinations. We pay for marginal end of life care for people, while others don't have meals on wheels, long-term care, respite care or emergency response systems and have no handy senior citizen centers.

The health care system can no more afford to do everything "beneficial" for every patient than the education system can do everything "beneficial" for every student, nor the police department do everything "beneficial" for every citizen, nor every parent do everything "beneficial" for their children. We are funding health care by an unsustainable yardstick.

Nor can a public policymaker "do no harm." Someone must locate the garbage dumps and the one-way streets, must parole prisoners (to make room for this year's crop of new inmates), set speed limits and myriad other tasks which inevitably cause "harm" because public policy can't help but inadvertently do some harm. No public policymaker should ever sign the Hippocratic oath.

What can we not do? We need to start now to discuss what we can morally leave undone. This is "...a dilemma so new that neither our social, legal and religious institutions, nor our health care providers or consumers, have developed a satisfactory way of coping," says Laurene Graig in Health of Nations: An International Perspective on U.S. Health Reform. Yet cope we must.

As Dr. David Eddy, policy expert with the Kaiser Permanente Health Care Program has said, "We will need to accept, once and for all, that resources are limited. It's the limitation on resources that both necessitates and justifies the strategy of getting more for less." This is painful but unavoidable. We are inventing the unaffordable and spending the unsustainable. We need to focus limited resources on where they will buy the most health for society.

The price of modern medicine in a high technology society is to decide what and whom to cover. We must find a way to do so and at the same time articulate the trade-offs involved. I suggest that when we deliver futile and marginal care, we are actually being unethical. In the new world of health care, when we overtreat A we take needed care away from B. The unintended end result of current medical ethics is unethical public policy and unethical macro decision making. The dollars we spend on marginal and futile care are no longer available to spend on needed care for someone else in the system or some other equally important social need.

Philosopher Haavi Morreim of the University of Tennessee School of Medicine writes of a new concept, "contributive justice," which changes the rules when making choices for those who contribute to a limited pool. From this viewpoint, my irrational or excessive use of limited funds prevents you or others from getting necessary care. Herein lies a yet undeveloped challenge to society for evaluating modern medicine by a new ethical perspective.

In a world that cannot deliver all the "beneficial" care to everyone, the existing ethics are inadequate to judge a health delivery system. If a system produces more health for a group, should we turn against it because it violates ethical standards applicable to an individual (and one which we admit is unsustainable)? In a world of limited resources, what if a group is better off not giving all the marginal care to individuals but instead maximizes the health of the group?

HOW DO WE JUDGE A HEALTH CARE SYSTEM?

Does America really have "the best health care system in the world?" It is clear that America has the most technologically advanced medicine, but brilliant medicine does not necessarily make a brilliant health care system. While there is virtually no question that in research, training, facilities and technology no nation tops the United States, most experts agree with Professor Robert Blank's concise analysis of our total system in his book The Price of Life: The Future of American Healthcare:

"Although there is no doubt that Americans have the most extensive range of sophisticated medical technology in the world, we fall well short of most other nations in health promotion, preventive medicine and access to primary care. Health outcomes as measured by morbidity and mortality rates fail to reflect the vast expenditure differential with other nations. Something, therefore, is dreadfully wrong." (emphasis added)

It is important to recognize that brilliant doctors and advanced technology alone are not enough to produce an excellent system. Why? Because a system is the sum of its parts, and a weak part anywhere weakens the system overall. What if we were to claim that we had the "best road system in the world," with beautiful, modern freeways, yet traffic movement was paralyzed by congestion, highways missed a significant part of the state and our traffic deaths were among the highest in the world?

A health care system should be evaluated by three criteria: 1) technology and training; 2) access by the entire population; and 3) outcomes and results. While the United States unquestionably excels in technology and training, in the other two categories it falls far short of other developed nations.

Despite the enormous amount of resources and talent expended on health care, 50 percent more than any other developed country, America has the most uninsured citizens and the most underinsured citizens in the developed world. Equally upsetting, our citizens are less healthy than those in Europe, Canada or Japan. We are even losing ground compared with other nations. The United States ranks 21 out of 27 countries in infant mortality; 17th for life expectancy of women; and 21st for life expectancy of men of the 29 developed countries.

Health providers can rightly say that those statistics are not their fault, but public policy must take responsibility for them. A doctor can rightly point out that these flow from unhealthy lifestyle, not inadequate medicine, but public policy does have an impact on smoking, alcohol, seat belts, illicit drugs and other non-medical causes of poor health.

CHANGING THE HEALTH ETHIC

If this reasoning is correct, it changes many of our standard yardsticks. We no longer should approve a drug, a new technology or a procedure if it offers only marginal benefits.

Health expert Reinhard Priester at the University of Minnesota says, "...providers should not do everything that maximizes benefit in an individual patient, since doing so may interfere with the ability of other patients to obtain basic services; rather, providers should treat each patient with a full range of resources as is compatible with treating patients yet to come. That is an ethical earthquake..."

We must revise our unsustainable health care culture. We are individuals with certain defined rights and duties and also we are members of a society which itself has rights. But when an individual contributes to a limited pool of resources, he enters a new contractual arrangement that cannot be evaluated by the normal standards. Here the system has an ethical duty to the other members of our group not to use limited resources on procedures that have a certain degree of marginal effectiveness. I submit that not only is Oregon's health prioritization ethical, but that it may be unethical not to have some system that sets priorities for limited funds. As Governor Kitzhaber has said so often, we must decide both who and what. It must occasionally consider the health of the group before considering the health of the individual.

A modern system, looking beyond the individual patient, may find as Kaiser has in Southern California that they can save twice as many women for two-thirds of the money by concentrating mammography on women between 50 and 70. Isn't that better than giving mammograms indiscriminately, especially if we use the money saved for other more health producing strategies?

No nation leaves its total defense policy to its generals, nor its educational policy to its teachers, nor its concept of justice to its lawyers. While the state cannot decide what medical care an individual needs, it can and must decide what policies produce the most health, and additionally set up a system to make the best use of the funds it does spend on health care.

Public policy has a broad responsibility and demands a panoramic view. We "ration" health care whenever we leave someone or something out of our health coverage. We can (and have) run from rationing, but we can't hide. We must, sooner or later, better assert the public interest in funding health care.

Richard D. Lamm, a former governor of Colorado, is director of the Center for Public Policy and Contemporary Issues at the University of Denver.