Health-care rationing.

In last year's struggle over health care reform, opponents of the Clinton ad ministration's initiative invoked the specter of government "rationing" The obvious implication was that rationing of health care does not exist in the United States today but would if the Clinton ad ministration had its way. Concerning this claim, a few observations must be made.

The United States has the most scientifically and technologically advanced medical care in the world. We have well trained and highly motivated physicians, dentists, nurses, pharmacists, X-ray technicians, lab technicians, dietitians, and other professionals who are able to pro vice the best possible care for patients. Our hospitals and other institutions make the best and most sophisticated equipment available to a significant segment of the population. However, the health care system of the richest and most powerful country on earth is increasingly an un just system in which access to medical care is rationed by the ability to pay. In this society, access to medical care is be coming more and more a benefit available only to the economically advantaged. Millions of Americans do not have health insurance or have inadequate insurance.

If rationing is defined as the withholding of potentially beneficial health care services from a certain category or group of individuals, it can be concluded that rationing occurs in the present system. Let us review some situations in which rationing of health care already occurs.

* Medicaid, a health insurance program for poor people, covers only 40 percent of the poor. Furthermore, because of the level of payments, reimbursement delays, and other concerns, many physicians refuse to take care of Medicaid patients. Thus, some Medicaid eligible patients, especially in rural and underserviced areas, have no access to health care because they cannot find providers to treat them.

* Due to high deductibles and increasing insurance premiums, access to health care is becoming more difficult for middle income families.

* Every year, more employers find them selves and their employees without adequate access to health care when firms are unable to cover the rising cost of health insurance premiums.

* Individuals with pre existing conditions--such as diabetes, heart disease, and HIV infection--are unable to obtain coverage at any price and have joined the ranks of the "uninsurable"

* The Medicare program covers people aged 65 and older but not 62 or 63 year-olds. This is an example of rationing by conscious public policy.

* Millions of Americans are born into families that have no health insurance; this may be considered rationing by luck or (to be more precise) bad luck.

Adequate access to health care is a basic human right closely related to the preservation and protection of human dignity. The health care system of this country needs genuine reform. We need a national health program that guarantees universal access to comprehensive care while containing costs and minimizing ad ministrative interference in the practice of medicine. We need a national health program that allows patients free choice of providers and physicians free choice of practice settings. We need a national health program that provides universal coverage regardless of age, sex, race, in come, sexual orientation, or any other factor. Furthermore, true health care reform cannot be accomplished without a radical change in the medical malpractice system that would eliminate frivolous lawsuits and the very expensive practice of defensive medicine.

Our current system offers the best quality care in the world--for those who are able to pay. As shown above, rationing is already a reality in our current system. Moreover, the United States spends more on health care than any other developed country, and health care will be far more costly in the future if pre sent policies remain unchanged.

This country of ours--the richest and greatest nation in the world--should be capable of designing and implementing a health,care system that provides access to basic care for all citizens and contains costs without restricting patient choice. A true reform will build on our strengths, providing high quality care to all Americans by instituting a universal system and eliminating excessive bureaucracy.

Dr. Jose Lozano is a founding member of the Texas chapter of Physicians for a National Health Program, an organization of health professionals advocating single payer reform. This article is adapted from his booklet Health Care Reform: A Physician's View.