Editor's blog 11 September 2008: An impressive debate starts the rationing ball rolling

by Andy Cowper, editor, Health Policy Insight

You know the old joke about mergers – ‘a merger is like two porcupines making love – it should be done carefully and slowly’?

Porcupines and their spines come to mind when thinking about the complex issue of topping-up NHS care. As do mergers. In effect, if the Richards Review on topping up for cancer drugs recommends that existing policy – NHS care is withdrawn from those who admit they are privately funding drugs or care the NHS will not offer – then we will see the merger of two very different systems, each with a distinct ethos.

It feels as if the balance of public opinion may have ‘tipped’ on topping up for cancer drugs. The balance of media opinion, led by the Sunday Times campaign, has probably tipped too.

But at the Kings Fund’s debate this morning (a rough transcript can be found here), it quickly became apparent that this illuminating and challenging issue cannot be separated from the broader issue of defining what the NHS will offer and what it will not.

Explicit rationing and the lottery
There are three things in life whose existence people don’t want to admit: healthcare rationing, negative equity and bad sex. Rationing is like negative equity in that it’s a fact of life now for many people, and an irrelevance to the seriously rich. It’s like bad sex because it won’t get better without looking hard at the root causes.

The theory that rationing per se is the answer is probably wrong in a demotic and democratic society like ours. The Oregon experience in the USA is instructive: to provide universal healthcare coverage, the state of Oregon extended public Medicaid state cover to all Oregon citizens below the federal poverty line.

The state then drew up a list and fixed a cut-off point above which, treatments were publicly funded and below which they were not. Legislation had initially aimed to compel Oregon’s  private employers to provide their workers with health insurance, but this was scuppered by business lobbying and the Republicans taking over state government.

Oregon’s rationing was much-heralded as ‘The Answer’ to universal medical cover and claimed to produce significant savings. However, subsequent research by Oberlander, Marmor and Jacobs showed that costs were not significantly reduced; the Medicaid package in fact became more generous than the previous one; below-the-line conditions were not excluded; coverathe scheme only reduced the uninsured from 17% to 6%, and clinicians were hijacking the scheme by reclassifying below-the-line treatments they deemed worthy for a patient (and vice versa) as above-the-line ones.

Talking about healthcare rationing might, however, enable a slightly more intelligent and less ideological public debate about public spending than is usual. It should certainly focus more attention on cost-effectiveness and outcomes within the NHS.

As Alan Maynard points out, hard budgets can force real attention onto the cost-effectiveness of services as well as their clinical effectiveness.

Oh, and what happened to healthcare in Oregon in the long run? You’ll find that nowadays, it’s a lottery. Literally.