Out in the Cold?

By DAVID VAN BIEMA

The day before Bill Clinton's health speech, the President and Hillary told reporters about their conversation with a hospital administrator. The man told them his institution had received a 92-year-old man for a quadruple-bypass operation, which would cost tens of thousands of dollars and extend his life marginally. Hillary asked why. The answer: Because there was no way to turn him away. Later, a journalist asked a sensitive question: If the old man hadn't been admitted, would it have been a form of rationing, er, "prioritizing"? This time the President answered, knowing the question was really about his own plan. "I'm not just trying to be the tooth fairy here," he said. "Every system has some rationing. The system we're in now severely rations care in all kinds of ways."

In even using the word in that way, Clinton had broken something of an Administration taboo. Rationing, the sacrificing of certain expensive or marginally useful treatments in the interests of economy, had been avidly discussed earlier in his tenure. In March Health Secretary Donna Shalala approved a Medicaid-distribution plan composed by the state of Oregon that ranked ailments and their attendant treatments from 1 to 709, according to their perceived costs and benefits. Then, based on the amount of money in its Medicaid budget, Oregon drew a line -- at number 587 -- between those it was willing to offer and those it wasn't. Some were appalled at the cold-eyed efficiency of the plan, which will go into effect this February. Others suggested that the Administration might want to impose that sort of bareknuckle rationing on the nation.

The idea was never seriously considered. "The R-word was absolutely forbidden," says an outside expert who attended health adviser Ira Magaziner's planning meetings. Quite shrewdly, it seems. In most opinion polls, citizens lean against rationing, even in the abstract.

Nevertheless, some of it will probably occur. Not classic, state-dictated rationing, with a star chamber headed by Magaziner deciding who gets dialysis or brain scans. But the competition Clinton hopes to inject into the system, combined with his proposed cap on insurance premiums, could cause insurance companies and HMOs to put pressure on their physicians, who in turn might respond by drawing lines not unlike Oregon's. Companies "will make rationing decisions in the privacy of their own boardrooms. I'd anticipate seeing significant cutbacks in care," predicts Steffie Woolhandler, a co-founder of Physicians for a National Health Program, which advocates the single-payer form of health care like Canada's tax-based government plan.

White House health advisers deny that any but the most obviously ineffective or redundant treatments might be eliminated through this process. Nevertheless, industry experts note that even without Clinton's nudge, physicians, clinical researchers, ethicists and health-care executives have struggled to clarify what tests and procedures should be classified as "futile care" or "marginally beneficial care." In the event that the pressure to economize were turned up, procedures like these might be curtailed:

Bone-marrow transplants for advanced breast-cancer patients allow some women + whose cancers have spread into 10 or more lymph nodes to undergo more intensive radiation therapy. The 1,200 instances in which the technique has been tried so far suggest that it may add several years to a patient's life -- at a cost of more than $100,000 a year. However, refinements may soon drastically reduce that to a far more cost-effective $17,000. Letha Mills, director of the bone-marrow transplant program at New Hampshire's Norris Cotton Cancer Center, is worried about the chilling effect that rationing would have had on the treatment's invention. "You can't just stop trying to develop new ways to cure people," she says.

Ultrasound exams may still be a vital diagnostic tool for women with high- risk pregnancies whose doctors know what they are looking for. But a six- year study of low-risk mothers who had undergone the procedure found that their children had exactly the same rate of birth defects, 5%, as those of women who didn't bother with it. "This is an example of the unnecessary testing that is driving up our health-care costs," said the lead investigator, Bernard Ewigman of the University of Missouri at Columbia. "Our findings are quite dramatic, and will surprise many physicians," as well as healthy pregnant women. If that group, which currently makes up 60% of the technology's users, were to forgo it, they would save a total of $500 million in bills.

Coronary bypass operations for patients over 80 generally produce bills twice as high as those for younger people, says Robert Jones, professor of surgery at North Carolina's Duke University. Jones, who heads a federally financed project to establish guidelines for cardiovascular surgery, explains that people like the nonagenarian of Clinton's anecdote stay in the hospital longer than younger people because of age-related surgical complications and the lack of people to care for them when they go home. As a result, says Jones, the pressure to turn down such high-risk, expensive patients "will be more than subtle. And in fact, it's already here."

Neonatal care for infants weighing less than 1.5 lbs. can run to $1 million per child if they spend several months in an intensive-care unit. Moreover, very few live long enough to leave the hospital, and half of those who do are debilitated. Such low-weight babies, who make up only 3% of the 300,000 preemies born each year, would seem to be a bad cost-benefit risk. But Alan Fleischman, director of neonatology at the Montefiore Medical Center in the Bronx, New York, notes that 20 years ago, only 10% of infants born weighing under 3 lbs. survived. The rate today is 90%. "Health-care alliances will come together and question these treatments, and the treatments for adults with terminal illnesses. But it's important for them to have some flexibility to allow innovation to flourish."

In some ways, rationing is the ultimate policy question. There is not a single question it raises that cannot be seen in a dozen different ways, and few that do not involve deciding that someone may die sooner than if the treatment had been given. To accept the need for rationing involves a certain pessimism -- the embracing of a zero-sum system where the only way to pay for one thing is to drop another. The pragmatic wonk in Clinton might want to wrestle with it; but the optimist in him, and his political instincts, will ensure that he will try to to keep it from becoming a focus of debate. He will probably succeed in this, since his plan is designed in such a way that any rationing that goes on will happen far from the White House. The odds are that America will have to wait until that plan is in place even to know where the really hard decisions are being made.

CHART: NOT AVAILABLE

CREDIT: From a telephone poll of 800 adult Americans taken for TIME/CNN on Sept 23 by Yankelovich Partners Inc. Sampling error is plus or minus 3.5%.

CAPTION: Would you favor a health-care-reform plan that provides coverage to all Americans but would not pay for some expensive procedures that provide only short-term benefits to the very old and the terminally ill?

With reporting by Rod Paul/Portsmouth and Dick Thompson/Washington