Rationing becomes latest lightning rod: White House: Decisions won't be arbitrary

New guidelines calling for women to get less frequent mammograms are a strong indication that Americans will face more rationing of health care in the future, critics of the congressional health care overhaul say.

The guidelines are causing an uproar because many Americans fear that faceless bureaucrats and studies will dictate how decisions about health care policies and insurance reimbursement are made.

"If Americans want a preview of what federal health care rationing is, this is a preview," said Rep. David Camp, R-Midland, in an interview earlier this month after new guidelines recommended that women ages 50 to 74 get mammograms every two years. The previous recommendation had been annual mammograms for women 40 and older.

The White House responded quickly to the concerns, saying, "Health insurance reform will stop rationing, not increase it."

The Obama administration said on its Web site, www.whitehouse.gov, that "rationing is already happening every day -- at the hands of insurance companies who decide whether or not you get coverage."

Debate centers on whether coverage will be limited

Marta Mendez won't be getting her teeth fixed or a new pair of glasses anytime soon.

Like many states with looming budget deficits, Michigan in July eliminated vision and most dental coverage for its Medicaid recipients like Mendez.

She doesn't use the word rationing to describe the state's change in policy, but she understands the impact of the decision on herself and other low-income Michiganders who qualify for Medicaid.

"I'm suffering for it and I pray to God it doesn't get worse," said Mendez, 55, of Detroit, as she sat in a small examination room at the Community Health and Social Services Center (CHASS) in Detroit, a program serving 14,000 Medicaid patients and uninsured people. "This isn't good, not just for me but for all the people."

Rationing has become the latest lightning rod in the national discussion about health insurance overhaul, as debate focuses on whether care would be curtailed to millions of Americans who already have insurance to hold down costs.

The issue was fanned earlier this month after an independent federal panel recommended that women 50 to 74 years old needed a mammogram every other year. Current guidelines call for annual mammograms after age 40.

The guidelines ignored decades of work to educate women about the benefits of yearly screening and breast self exams and are a harbinger of what's to come, said Rep. David Camp, R-Midland. Health overhaul will impose more guidelines that will affect insurance coverage by creating "well over 100 boards and commissions" that will dictate policy and coverage decisions without congressional approval, Camp said this month.

The difference is that "the government doesn't have the authority now" to dictate benefits and coverage, he said. "Congress sets the policy on who is paid and what is paid" in government programs like Medicare and Medicaid.

The Obama administration and others say health reforms will eliminate arbitrary decisions by insurers to deny or limit care and that studies will focus on what works, to give incentives to the best, proven treatments.

The mammography flap shows that "most people have been led to believe that rationing is not part of health care right now," said Leonard Fleck, professor of philosophy and medical ethics at Michigan State University. He is the author of "Just Caring: Health Care Rationing and Democratic Deliberation" published this year by Oxford Press. He supports reforms for many reasons, including the fact that government decisions must be public, rather than those adopted quietly by insurance companies.

Americans "need to understand that you cannot demand lower taxes and infinitely expansive health care services paid for by government funds, Fleck said. He called disingenuous attacks by Republicans on Democratic proponents for driving up health costs with new programs, at the same time they are accusing them of rationing.

Health policy experts say the debate ignores the fact that the U.S. and most other nations already ration care.

Some examples: caps on annual and lifetime limits on benefits; requiring prior authorization to see a specialist, and charging consumers higher co-pays for brand-name drugs.

Dr. A. Mark Fendrick, a physician and health policy specialist at the University of Michigan, said guidelines can help government and insurance executives make good decisions on reimbursement based on science, not arbitrary factors like insurance status. "If you are going to ration, I'd much prefer rationing based on clinical benefits rather than one's ability to pay," he said.

"There are 40-plus-million Americans with no insurance who certainly do not get the same level of care as those who have insurance," he said. "This is rationing by one's ability to pay for services."

History gives insights into how intolerant Americans have been, and would be, if reforms go too far, said Dr. John Birkmeyer, a University of Michigan surgeon and health policy specialist.

In 1994, after the Agency for Healthcare Policy and Research issued guidelines that questioned the value of back surgery, orthopedic surgeons lobbied the government to back off the recommendations, Birkmeyer said.

The pressure was so heated that the government also changed the name of the agency to clarify its role in studying science, not setting policy.

"They defanged all the research teams and went so far as to change the title of the agency to take the word policy out of it," he recalled. It was renamed the Agency for Healthcare Research and Quality.