I have written a lot about health care and the reform package. I have written so much and read so much that at times I forget that I may need to simplify my descriptions. Although I have written about rationing previously (found here) when I reviewed it I realized that it is a little dense for the average reader. My friend Fred Meyer is such a reader. We were having an impassioned discussion (fueled by AndyGator beer) about the obligation to provide healthcare and the need to curb costs. His comment about the methods I proposed to curb costs was “That’s rationing.” I replied that we are already rationing. I was unable to break down my very complex understanding of how we already ration into words that an orthopedist could understand so we moved on to telling Navy stories. For Fred I have found a simple-to-read article about rationing. In short, here is how we ration now:

First, by making people choose healthcare over other goods and services or choose to opt out of the system.

The rapid rise in medical costs has put many employers in a tough spot. They have had to pay much higher insurance premiums, which have increased their labor costs. To make up for these increases, many have given meager pay raises.

This tradeoff is often explicit during contract negotiations between a company and a labor union. For nonunionized workers, the tradeoff tends to be invisible. It happens behind closed doors in the human resources department. But it still happens. When health costs have grown fastest over the last two decades wages have grown slowest, and vice versa.

So when middle-class families complain about being stretched thin, they’re really complaining about rationing. Our expensive, inefficient health care system is eating up money that could otherwise pay for a mortgage, a car, a vacation or college tuition

Second, by letting people who opt out of (or were never let into) the system die prematurely.

The uninsured still receive some health care, obviously. But they get less care, and worse care, than they need. The Institute of Medicine has estimated that 18,000 people died in 2000 because they lacked insurance. By 2006, the number had risen to 22,000, according to the Urban Institute.

And thirdly, by providing care that is based on gaming the system rather than delivering a value added service (as I discussed in more detail here)

The final form of rationing is the one I described near the beginning of this column: the failure to provide certain types of care, even to people with health insurance. Doctors are generally not paid to do the blocking and tackling of medicine: collaboration, probing conversations with patients, small steps that avoid medical errors. Many doctors still do such things, out of professional pride. But the full medical system doesn’t do nearly enough.

In summary, we already ration. We just need to do it better and more transparently.