Democrats are against health care rationing if it's done by insurance companies. Republicans are against it if it's done by government.
What neither side will admit is that medical rationing is part of the future. We can't afford a system where everybody gets whatever care they want regardless of cost and effectiveness. The only question is whether we'll ration intelligently and fairly. Or not.
We ration health care today. Medicare fully pays for only three weeks of rehab after a hospital stay. That's rationing.
When your insurance company covers only 30 days of inpatient psychiatric treatment, that's rationing. When Medicaid covers people making a certain portion of poverty-level income but rejects those making slightly more - ditto.
"We don't have unlimited resources to spend on health care," says Dr. Sean Tunis, head of the Center for Medical Technology Policy in Baltimore. "And we're already neglecting other important social needs because there's simply not enough money."
Republicans are supposed to get this. They're supposed to be the party that understands waste, limits, cost/benefit trade-offs and what happens when you let people (patients and doctors) spend somebody else's money (insurance companies' and taxpayers').
These days they sound like their own caricature of a Democrat, pretending that resources are endless, that everybody gets what they want and that measuring efficiency is the same as euthanasia.
Tunis is in the middle of all this because he's helping lead the parade on "comparative effectiveness," the long-overdue effort to find out why the United States spends roughly 70 percent more on health care (as a portion of its economy) than other developed countries but gets worse results.
Until 2005, he was chief medical officer at the Centers for Medicare and Medicaid Services in Woodlawn, overseeing quality and clinical standards for the huge government programs. He founded the Center for Medical Technology Policy to help doctors and patients learn which new procedures and pills work best. In February he was appointed to a federal committee on comparative effectiveness created by the stimulus bill.
But even he doesn't sound very optimistic that what he's doing will affect policy or practice any time soon. He does what he does, he says, "based on the faith that somewhere in the near future there will be a market for the information."
That's some faith. Republicans opposed money for comparative effectiveness in the stimulus bill. Former Alaska Gov. Sarah Palin says the Democrats' proposal will lead to "death panels" that might deny care to the disabled.
"We should not have a government program that determines if you're going to pull the plug on Grandma," Iowa Republican Sen. Charles Grassley said this week, in remarks first reported by the Iowa Independent.
With such poison in the air, maybe you can't blame Democrats for soft-pedaling the incompatibility of the country's medical wants and its ability to pay.
"If there's a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half price for the thing that's going to make you well?" President Barack Obama suggested last month.
But it's rarely that clear-cut. The more likely scenario is that the red pill works 10 percent better than the blue pill but costs 10 times as much.
Smart policy, Tunis says, would set up incentives for doctors and patients that reflect the costs and benefits of various treatments.
Make the red pill available but charge a premium to encourage use of the more efficient blue pill. Let the weekend jock with a knee injury get an immediate MRI if that's what he and his doc think is best. But make him share the cost, so that he considers waiting a couple of weeks to see if the knee heals on its own.
This is the discussion we need to have. But it's not happening.
If reform fails we'll keep the present setup, which rations care in an unfair, haphazard and incredibly inefficient way.
"We have to recognize that right now we have a health care system in which everybody doesn't get everything they could possibly benefit from," says Ruth Faden, director of the Johns Hopkins Berman Institute of Bioethics. "How it's determined who does or doesn't get whatever they get - right now it's profoundly unethical. And not to acknowledge that is to just be naive."
Even if you have health insurance, you may be subject to severe rationing and just haven't figured it out. What if you got really sick? What are the lifetime payment caps on your policy? What are the limits on hospitalization? Check the fine print. "Socialized" medicine might start to look OK.
Most medical care is virtually socialized, anyway. Private insurance takes contributions from the many to help the needy few - the sick. Can you really distinguish the faceless bureaucrats at Cigna from the faceless bureaucrats at Medicaid?
Modern health care needs administration, priorities, choices and direction. It needs the best information on what works and what doesn't. Hysteria that blocks such information hurts patients, taxpayers and especially future taxpayers - our poor grandchildren who will get stuck with most of the bill.