In the last few years, the U.S. health care system has seemingly been gripped by “back to the nineties” fever. Back then, we had a Democratic president working to reform the health care system. Experts from across this system were promoting the importance of controlling health care costs; the growth of health care expenditures even slowed considerably around that time. Now we have a Democratic president who not only tried to reform the health care system but also managed to pass a complex health care law. As in the nineties, experts have been promoting the importance of controlling health care costs, and health care expenditures have even slowed over the past four years.
But for those working at the intersection of health care policy and ethics, there is a notable change in professional debates about how to better control health care costs. Discussion of health care rationing, which was hotly debated in the nineties, has become much more muted. The decline of rationing debates may reflect shifting emphases in health care policy. In the nineties, managed care companies (which the Clintons hoped to promote in their reform efforts) were capitating medical care, paying health care providers lump sums to care for panels of patients, thereby giving them a financial incentive to withhold medical care in order to hold on to some of that money. Such a strong incentive to withhold care inevitably sparked rationing fears.1 By contrast, the Affordable Care Act promotes accountable care organizations,2 which for the most part function on an old-fashioned fee-for-service basis, with modest incentives to contain costs while demonstrating high-quality care.
Rationing debates may also have declined because of changes in how policy experts analyze health care delivery. Back in the nineties, medical ethicists and health care experts debated the pros and cons of cost-effectiveness analysis,3 an economic tool that its proponents contended would demonstrate the most rational way to ration care.4 For a while, Oregon even tried to ration services to its Medicaid population using cost effectiveness in order to maximize the number of people it could enroll in Medicaid without surpassing its budget.5 In policy discussions now, however, cost-effectiveness analysis is practically nonexistent, replaced by comparative effectiveness research, a set of noneconomic analyses meant to guide health care decision-making without relying on rationing. Indeed, the ACA promotes the idea of CER while specifically requiring federal funding of such research not to be directed toward studies of cost.
In the nineties, bioethicists pumped out articles and books endorsing the idea of health care rationing while trying to determine the best way to ration care in a just manner.6 Now? The ethics of health care rationing seems to have faded from the literature.
Is health care rationing passé? I contend that debates about health care rationing have waned not because the need to ration has dwindled nor because ethical debates about how or whether to ration have been resolved. They have declined because the word “rationing,” and unrelated concepts such as cost-effectiveness analysis, have been replaced by terms— “parsimony,” “value,” and “CER”—that are not burdened by emotional and historical baggage. Terms like “rationing” and “cost effective” create strong emotions that interfere with rational argument. The newer terms, by contrast, may allow us to reengage in healthy debates about the best way to control health care costs without getting distracted by our preexisting thoughts and feelings.
Sometimes the best way to promote healthy moral debate is to turn to new words that don’t carry the burden of past debates.