In a single-payer system, who will be doing the rationing?

One of the arguments made against adopting single-payer health care in this country is that it would “lead to rationing.” This assumes that we lucky people in the U.S. have unlimited access to whatever health care we need and are at risk of losing it.

This argument came to mind when I saw a few recent news items. One was that a federal judge, U.S. District Judge Robert Scola, recused himself from a case in which a cancer patient was suing United Healthcare for their refusal to cover the recommended proton beam therapy for his prostate cancer. Judge Scola said he could not rule on the case impartially because he himself had been treated for prostate cancer and had been offered proton beam therapy (though he ultimately chose surgery). In his order of recusal, he wrote: “To deny a patient this treatment, if it is available, is immoral and barbaric.”

The Boston Globe featured an article about a young woman with advanced cancer of the cervix who was referred to Massachusetts General Hospital for proton beam therapy whose insurer refused to pay for the treatment despite multiple appeals.

Moving from anecdotes to a larger sample (and I am well aware that the plural of anecdote is not data), I found a survey conducted among radiation oncologists this Spring. Nine out of ten said their patients faced delays in getting recommended therapy for their cancers. Almost a third (31 percent) said that such delays lasted more than five days, the equivalent of a standard week of therapy.

The reason that this is important is that for every week therapy is delayed, there is about a 2 percent increase in mortality. Almost two thirds (62 percent) said that the denials were ultimately overturned on appeal, making one wonder why the therapy was denied in the first place. Having been harassed for years by insurance company clerks over getting approval for tests and treatments, I have my own theory, which is that the insurer hopes that blanket denials will weed out many expenses, as the doctor will be too busy or frustrated to spend the time to appeal, thus saving the insurer money.

An AMA survey in 2018 of 1,000 physicians found that 92 percent felt that prior authorization programs delay access to care, with 78 percent saying that prior authorization causes some patients to abandon recommended tests or treatments. Maddeningly, 30 percent said they had waited three or more days to get a decision from the insurance company. The radiation therapists noted that when their appeals reached the point of speaking to a “peer,” the physician with whom they spoke was rarely in that field and often demonstrated little knowledge of the problem being addressed.

Put this together with Aetna’s recent settlement of a lawsuit alleging that their physician reviewers rarely even read the patients’ records before issuing denials, and one sees a pattern. While there is room for legitimate disagreement about the value of some therapies, it is inappropriate for the insurer, with a clear financial stake in the decision, to be the decision-maker about what tests and therapies are covered. In any rational health care system, the determination about paying for a procedure would be made by disinterested experts who could look at the scientific evidence and make a recommendation with no financial stake in the outcome.

Rationing? We have rationing now, but the rationing is done by those who save money from doing this. In my ideal system, patients, clinicians, and statisticians would make evidence-informed guidelines. In the absence of such a rational process, I would rather this be done by “bureaucrats” than by the for-profit insurers as it is now.

Edward Hoffer is an internal medicine physician and author of Prescription for Bankruptcy: A doctor’s perspective on America’s failing health care system and how we can fix it. He blogs at What’s wrong with health care in America?

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