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Vilifying Dr. Berwick — for the Wrong Reasons

If you don’t like ObamaCare, you probably really don’t like Donald Berwick, the current administrative head of Medicare and Medicaid.

You know him. He’s the one who’s “in love” with the Britain’s National Health Service, the guy who insists that we “must — must — redistribute wealth,” and tells us that, since rationing is unavoidable, we’d best do it “with our eyes open.”

But in regards to government-funded health care — including Medicare and Medicaid — Dr. Berwick is right, so it does no good to shoot the messenger.

Medicare, Medicaid, and all collectivized medical care require rationing for the simple reason that all scarce resources must be rationed.

When you and I live within our means, we’re rationing. Although we usually think of it as budgeting, what we do is figure out how much money we have to work with, set our priorities, and then ration our resources accordingly. Some for food and housing. Some for medical care. Some for our kid’s education and future. We each have different sets of priorities and values, so our spending is highly individualized and personal. We get to do this, because we own those resources. Because what we would like to spend far exceeds what we can spend (as limited by our personal financial reserves) we must privately ration.*

The need to ration doesn’t change simply by pooling resources. In fact, pooling resources into common ownership makes planning all the more difficult. When medical resources are collectivized, we turn the industry which cares for us when we are injured, ill, or dying into a Tragedy of the Commons. Instead of Hardin’s example of cattle overgrazing the land, our infinite demand for health care leads to rising prices and a soaring national debt — unless we ration.

Without rationing, we will run up trillions of dollars of debt and drive the country towards bankruptcy. Oh, wait. We’re already doing that … and without rationing, it’s going to get much worse.

In a free society, individuals make their own rationing decisions according to personal priorities and privately owned resources. If a neighbor’s help is needed, it must be asked for and then given voluntarily. When resources are collectivized (or nationalized, or socialized, it’s all the same thing) a central decision making body must do the rationing. Individual personal priorities are subordinated to the priorities of the group — which in practice ends up being a small group of the politically powerful.

That’s why Medicare needs the Independent Payment Advisory Board. Setting a cap on spending is the first step of rationing. The next is deciding who gets what medical care.

“Limited resources require decisions about who will have access to care and the extent of their coverage.” (Berwick, 1999)

As physician-blogger Dr. Richard Fogoros puts it: we can either ration overtly or covertly (“with our eyes open” or closed) — but ration we must.

The only way to escape the need for centralized rationing is to recognize that health care expenditures are not a national phenomenon, but an individual one. We have to stop thinking of medical care in collectivist terms, such as a “national resource” available for dispersal through political wrangling. Medical care is of, for, and by private individuals.

The proper alternative to the increasingly top-down, coercive central planning integral to our current system is restoring to each of us the right and responsibility for making our own rationing decisions.

Go ahead and vilify Dr. Berwick. There’s plenty not to like.

But if you support Medicare, Medicaid, the ACA or any other variation of government-run medical care, then plan on handing your wallet to the federal government, while Dr. Berwick and the central planners tell you what medical care you can have.

*(This is not to imply that markets or prices ration. They do not. Markets are simply a mechanism of exchange. Free markets signal through prices the scarcity of items based on supply relative to demand. Markets and prices don’t ration. People ration — either voluntarily as individuals, or coercively through government.)

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