Which is more valuable? To provide a $150,000 liver transplant for an ailing child of indigent parents? Or to use that money for prenatal care that may enhance the life expectancy of fetuses being carried by 150 expectant mothers? To most Americans, the either/or aspect of the question is morally repugnant — surely the leader of the democratic capitalist world can afford both. Yet a growing number of health experts argue that the U.S., in fact, no longer has the financial resources to provide unlimited medical treatment for all those who need it. The only solution, they say, is rationing health care. The state of Oregon and California’s Alameda County, which includes Oakland, are on the verge of taking that seemingly drastic step. In April, the Oregon senate passed a bill that would extend Medicaid coverage to 86,000 low-income people previously not covered. There would, however, be limits to the care they could expect. The measure, now before the lower house, would also establish a commission of experts and consumers to rank health services in order of importance; the legislature would then decide which to finance. Oregon has already set up committees of doctors, nurses and social workers to & establish priorities in four medical categories covered by Medicaid. Prenatal care, nutrition, immunizations, birth control and abortions rank high on the lists, while organ transplants and cosmetic surgery have been given low priority. In Alameda County, the board of supervisors last January hired a professional ethicist to assist a committee of medical experts in deciding what specific services will be made available to the county’s uninsured poor. “It’s scary,” says Dr. Marye L. Thomas, Alameda’s director of mental health and a member of the committee. “As a physician, I was trained to give the best possible care to anyone, period. Back when I was in medical school, I never thought I would be discussing this.” Health officials cite grim statistics as evidence that they are acting out of fiscal need, not cruel disregard for human suffering. In Alameda, roughly 75% of the county’s $278 million health-care budget comes from state and federal sources. But that money is drying up. For example, state funds are currently only about one-half of what the county received in 1982. Health administrators argue that rationing is a pointed way of telling legislators they must bear the responsibility for their budgetary decisions. In a sense, rationing medical care is a form of triage — the mellifluous French term, derived from wartime practice, for giving medical attention to the most likely survivors. This goes against the American grain. According to a 1987 Harris poll, more than 90% agreed with the statement that “everybody should have the right to get the best possible health care — as good as the treatment a millionaire gets.” But another survey, by the Public Agenda Foundation, found that only one person in ten would accept a $125 tax increase to support a national insurance program for catastrophic illness. As medical costs rise at an annual rate of more than 15%, public health facilities try to cope with the needs of the 37 million Americans — about 15% of the population — who have no medical insurance at all. “We want to be all things to all people, but the money’s just not there,” says Dr. Tom Miller of Alameda County’s public health department.
