healthcare rationing in the united states healthcare rationing in the united states healthcare rationing in the united states exists in various forms. access to private health insurance is rationed on price and ability to pay. those unable to afford a health insurance policy are unable to acquire a private plan except by employer-provided and other job-attached coverage, and insurance companies sometimes pre-screen applicants for pre-existing medical conditions. applicants with such conditions may be declined cover or pay higher premiums and/or have extra conditions imposed such as a waiting period. this article is part of a series onhealthcare reform in theunited states history debate legislation preceding social security amendments of 1965 emtala (1986) hipaa (1996) medicare modernization act (2003) psqia (2005) superseded affordable health care for america (h.r. 3962) america's affordable health choices (h.r. 3200) baucus health bill (s. 1796) proposed american health care act (2017) medicare for all act (2021, h.r. 1976) healthy americans act (2007, 2009) health security act (h.r. 3600) latest enacted affordable care act (h.r. 3590) health care and education reconciliation act (h.r. 4872) reforms obama administration proposals public opinion reform advocacy groups rationing insurance coverage systems free market health insurance exchange nationalized insurance publicly-funded single-payer canadian vs. american two-tier universal third-party payment models all-payer rate setting capitation fee-for-service global payment united states portal health care portal the poor are given access to medicaid, which is restricted by income and asset limits by means-testing, and other federal and state eligibility regulations apply. health maintenance organizations (hmos), which are common among the rest of the population, restrict access to treatment by financial and clinical access limits. those 65 and older and a few others also qualify for medicare, but it also has many restrictions. in the media and in academia, some have advocated explicit healthcare rationing to limit the cost of medicare and medicaid. they argue that a proper rationing mechanism would be more equitable and cost-effective. the congressional budget office (cbo) has argued that health care costs are the primary driver of government spending in the long term. background peter singer wrote for the new york times magazine in july 2009 that healthcare is rationed in the united states: "health care is a scarce resource, and all scarce resources are rationed in one way or another. in the united states, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. but our current system of employer-financed health insurance exists only because the federal government encouraged it by making the premiums tax deductible. that is, in effect, a more than $200 billion government subsidy for health care. in the public sector, primarily medicare, medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals." david leonhardt wrote in the new york times in june 2009 that rationing presently an economic reality: "the choice isn't between rationing and not rationing. it's between rationing well and rationing badly. given that the united states devotes far more of its economy to health care than other rich countries, and gets worse results by many measures, it's hard to argue that we are now rationing very rationally." he wrote that there are three primary ways the us rations healthcare: the increases in healthcare premiums reduce worker pay. in other words, more expensive insurance premiums reduce the growth in household income, which forces tradeoffs between healthcare services and other consumption. the increases also prevent smaller companies from affording health insurance for their workers. the cost prevents the certain types of care from being provided. during 2007, nearly 45% of us healthcare expenses were paid for by the government. in 2009, an estimated 46 million individuals in the united states did not have health insurance coverage. in 2008, tia powell led a new york state work group to set up guidelines for rationing ventilators during a potential flu pandemic. methods used by insurance companies dr. gerald grumet has chronicled how private insurers and third party payers delay and impede the utilization of medical services through creating inconvenience and confusion for both patients and physicians through complex claims review processes with layers of administrative handling that supersede the autonomy of treating physicians. president obama noted that us healthcare was rationed based on income, type of employment, and pre-existing medical conditions, with nearly 46 million uninsured. he stated that millions of americans were denied coverage or face higher premiums because of pre-existing medical conditions. in an e-mail to obama supporters, david axelrod wrote, "reform will stop 'rationing' - not increase it.... it's a myth that reform will mean a 'government takeover' of health care or lead to 'rationing.' to the contrary, reform will forbid many forms of rationing that are currently being used by insurance companies." a 2008 study by researchers at the urban institute found that health spending for uninsured non-elderly americans was only about 43% of health spending for similar, privately insured americans. that implied rationing by price and ability to pay. fareed zakaria wrote that only 38% of small businesses provided health insurance for their employees during 2009, versus 61% in 1993, because of rising costs. an investigation by the house subcommittee on oversight and investigations showed that health insurers wellpoint inc., unitedhealth group and assurant inc. canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over five years. it also found that policyholders with breast cancer, lymphoma, and more than 1000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses. private and public insurers all have their own drug formularies through which they set coverage limitations, which may include referrals to the insurance company for a decision on whether the company will approve its share of the costs. american formularies make generalized coverage decisions by class, with cheaper drugs at one end of the scale and more expensive drugs with more conditions for referral and possible denial at the other end. not all drugs may be in the formulary of every company, and consumers are advised to check the formulary before they buy insurance. the phenomena known as medical bankruptcy is unheard of in countries with universal health care in which medical copayments are low or no nonexistent. in the united states, however, research shows that many bankruptcies have a strong medical component, even among the insured. medical insurance before the affordable care act allowed annual caps or lifetime caps on coverage, and the high cost of care made it common for insured persons to suffer bankruptcy after breaching those limits. by price a july 2009 npr article quoted various doctors describing how america rations healthcare. dr. arthur kellermann said: "in america, we strictly ration health care. we've done it for years.... but in contrast to other wealthy countries, we don't ration medical care on the basis of need or anticipated benefit. in this country, we mainly ration on the ability to pay. and that is especially evident when you examine the plight of the uninsured in the united states." rationing by price means accepting that there is no triage according to need. thus, in the private sector, it is accepted that some people get expensive surgeries such as liver transplants or non-life-threatening ones such as cosmetic surgery, when others fail to get cheaper and much more cost-effective care such as prenatal care, which could save the lives of many fetuses and newborn children. some places, like oregon for example, explicitly ration medicaid resources by using medical priorities. polling has discovered that americans are much more likely than europeans or canadians to forgo necessary health care (such not seeking a prescribed medicine) on the grounds of cost. according to a recent survey commissioned by wolters kluwer, the majority of physicians and nurses (79%) say the cost to the patient influences the treatment choices or recommendations the provider makes. rationing by pharmaceutical companies pharmaceutical manufacturers often charge much more for drugs in the united states than they charge for the same drugs in britain, where they know that a higher price would put the drug outside the cost-effectiveness limits applied by regulators such as nice. american patients, even if they are covered by medicare or medicaid, often cannot afford the copayments for drugs, which is rationing based on ability to pay. rationing by government control after the death of coby howard in 1987 oregon began a programme of public consultation to decide which procedures its medicaid program should cover in an attempt to develop a transparent process for prioritizing medical services. howard died of leukaemia, which was not funded. his mother spent the last weeks of his life trying to raise $100,000 to pay for a bone marrow transplant, but the boy died before treatment could begin. john kitzhaber began a campaign arguing that thousands of low-income oregonians lacked access to even basic health services, much less access to transplants. a panel of experts was appointed, the health services commission, to develop a prioritized list of treatments. the state legislators decided where on the list of prioritised procedures the line of eligibility should be drawn. in 1995 there were 745 procedures, 581 of which were eligible for funding. republican newt gingrich argued that the reform plans supported by president obama expand the control of government over healthcare decisions, which he referred to as a type of healthcare rationing. he expressed concern that although there is nothing in the proposed laws that would constitute rationing, the combination of three factors would increase pressure on the government to ration care explicitly for the elderly: an expanded federal bureaucracy, the pending insolvency of medicare within a decade, and the fact that 25% of medicare costs are incurred in the final year of life. princeton professor uwe reinhardt wrote that both public and private healthcare programs can ration and rebutted the concept that governments alone impose rationing: "many critics of the current health reform efforts would have us believe that only governments ration things.... on the other hand, these same people believe that when, for similar reasons, a private health insurer refuses to pay for a particular procedure or has a price-tiered formulary for drugs – e.g., asking the insured to pay a 35 percent coinsurance rate on highly expensive biologic specialty drugs that effectively put that drug out of the patient's reach — the insurer is not rationing health care. instead, the insurer is merely allowing "consumers" (formerly "patients") to use their discretion on how to use their own money. the insurers are said to be managing prudently and efficiently, forcing patients to trade off the benefits of health care against their other budget priorities." during 2009, former alaska governor sarah palin wrote against rationing by government entities, referring to what she interpreted as such an entity in current reform legislation as a "death panel" and "downright evil." defenders of the plan indicated that the proposed legislation, h.r. 3200, would allow medicare for the first time to cover patient-doctor consultations about end-of-life planning, including discussions about drawing up a living will or planning hospice treatment. patients would be allowed but not required to seek out such advice on their own. the provision would limit medicare coverage to one consultation every five years. however, as governor, palin had supported such end of life counseling and advance directives from patients in alaska in 2008. ezra klein described in the washington post how polls indicate senior citizens are increasingly resistant to healthcare reform because of concerns about cuts to the existing medicare program that may be required to fund it. that is creating an unusual and potent political alliance, with republicans arguing to protect the existing medicare program although they historically opposed that and other major entitlement programs. the cbo scoring of the proposed h.r. 3200 (america's affordable health choices act of 2009) included $219 billion in savings over 10 years, some of which would come from medicare changes. by economic value added a concept called "quality-adjusted life year" (qaly - pronounced "qualy") is used by australian medicare to measure the cost-benefit of applying