Readers respond to a writer’s defense of the health reform law. The Letter To the Editor: Starting on Monday, the Supreme Court will consider constitutional challenges to the Affordable Care Act, hearing arguments about Congressional authority to mandate the purchase of health insurance by individuals and threats to states’ sovereignty by an expansion of state obligations under Medicaid. Although not likely to be struck down in its entirety, the law will continue to face stubborn opposition accompanied by lingering charges that “death panels” will ration health care. Many Americans mistakenly believe that Canada and Britain ration care while we do not. In reality, we also ration care, not through waiting lists but through high prices that impede access for those with no or limited insurance. This inconvenient truth has been twisted into a convenient lie by reform opponents to confuse the public. The specter of rationing has also been invoked by those seeking to repeal the Independent Payment Advisory Board — a panel that would recommend ways to lower Medicare costs — so that Congress and special interests may retain firm control over Medicare spending cuts. By delegating responsibility to independent experts, such a board would help depoliticize the existing process. Lost in the rhetoric is the Affordable Care Act’s efforts to reduce rationing through mandatory coverage of preventive services and essential minimum benefits. The act holds promise for more rational allocation and consumption of scarce resources. But first, we must accept the fact that rationing already exists but needs to be made more equitable if we are to achieve better health for our citizens and better value for our health care dollars. ALAN B. COHEN
Boston, March 20, 2012 The writer is a professor of health policy and management at Boston University School of Management and executive director of its Health Policy Institute. Readers React Of course we now have rationing through financial access barriers. It’s naïve to pretend otherwise. The Affordable Care Act will help move some people into insurance and, through banning exclusion for pre-existing conditions, allow some to become insurable at reasonable rates for the first time. But it certainly will not fix everything and may even worsen some problems: ¶It does little to restrain overall health system costs, a most serious issue. ¶It does nothing to improve providers’ unwillingness to accept Medicaid patients. ¶It fails to address fundamental problems with payment mechanisms and levels, as well as the training and distribution of health professionals. So, like it or not, rationing will continue. Do we ration rationally, or do we let the free market set the rules? Oregon instituted a widely supported Medicaid benefit package 20 years ago that faced these thorny rationing questions. Are the rest of us unwilling to catch up? ANN ZUVEKAS
Annandale, Va., March 21, 2012 The writer is a retired professor of health policy at The George Washington University. Professor Cohen criticizes those who want to repeal the Independent Payment Advisory Board for invoking “the specter of rationing.” That ignores an immediate and crucial concern. The board will be composed of 15 presidential appointees, unaccountable to the public. It will be given the task of cutting billions in Medicare expenditures — largely by denying government reimbursement for new and innovative medicines. In other words, its only viable option will be to further ratchet down reimbursement rates for providers, especially doctors, who are already losing money on Medicare patients. Indeed, according to the American Medical Association, the financial burden of too-low payments under Medicare has driven 17 percent of doctors and 31 percent of primary care doctors out of the Medicare program altogether. If rates fall any lower, seniors will have an increasingly difficult time securing doctor appointments. Visits will be cut short to squeeze in patients and care compromised. The board is even more insidious because it deflects policy makers’ attention from innovative reform efforts with real cost-saving potential. PETER J. PITTS
New York, March 21, 2012 The writer is president of the Center for Medicine in the Public Interest and a former associate commissioner of the Food and Drug Administration.
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