Victor Fuchs, the health economist, has an essay in a recent New England Journal of Medicine regarding health care rationing. Dr Fuchs has been writing and thinking about health care for a long time. If you are unfamiliar with his work, here are some quotes from an interview in 2000:

When asked how Americans will respond to health reform –

Two-thirds of the American people say they favor universal coverage, but the minute you start to spell out what that means — subsidization for the people who are poor and who are sick, and that the plan has to be compulsory — they are less supportive

When asked what is driving up the cost of health care –

The principle factor by far is medical innovations like new drugs, new surgical procedures and new diagnostic techniques. This is [confirmed by other] health economists in the country.

When asked if more medical care would make us more healthy –

I’m saying that almost everyone is getting the medical care that matters to health. Adding more care does not make much difference. The stuff that’s really effective, the antibiotics, the appendectomies and so forth — people get them. Health depends much more on the things we do to and for ourselves or that we don’t do. It depends on cigarette smoking, it depends on obesity, it depends on certain environmental conditions.

When asked what should we do to improve our health –

Improved health will come about through changes in the physical and psychosocial environments and in individual behavior and in medical advances, not in increasing the quantity of medical care at a given point in time.

In the recent New England Journal essay, Dr Fuchs identifies the payment structure as a significant barrier to reducing health care costs

The context… will affect the physician’s choice. If the physician is paid on a fee-for-service basis and the patient has open-ended insurance, the scales are tipped in favor of doing as much as possible and against limiting interventions to those that are cost-effective. In that setting, who would benefit from the resources that are saved by practicing cost-effective medicine is not obvious to the physician.

He believes that changing the payment structure to create an environment where the physician is responsible for the totality of care of a defined population will cause the physician to make better decisions based on a different frame of reference. He also believes that the patient will more readily accept physicians decisions not to recommend marginally effective care based on a “group good” in this context. Being in it together will help us to reduce both supply (from the doctors side) and demand (from the patients). There are several components of the Affordable Care Act including the Accountable Care Organization vehicle that use this strategy to reduce health care costs.

There is one other problem…who picks which group of people are in the health care lifeboat together? In doing some research on another topic, I came across this quote taken from a 1968 interview with a Mobile landlord regarding his plan to move his rental housing to an unincorporated area rather than offer city services (garbage pick up, sewerage and running water) to his (African-American) tenants:

“These people don’t mind,” he said. “You know, that’s the way with niggers. They’ll be happy in a community–everybody together. They try and go back to African tribal life. He don’t need garbage service–a darkie will feed it to his pigs. He don’t need a bathtub–he’d probably store food in it. Wouldn’t know how to use it.”

Granted, it was a different time. In conversations I have had with people both in and out of healthcare, though, I am concerned that we are still not certain that our neighbors are all striving for the same healthcare goals that we are. In the last 60 years we have come to realize that everyone likes to feel clean, regardless of skin color. How long will it take for us to believe that everyone wants to be healthy.