Correspondence

What is Rationing?

N Engl J Med 1999; 341:213July 15, 1999

Article

To the Editor:

We enjoyed reading Dr. Ginzberg's editorial on the uncertain future of managed care (Jan. 14 issue).1 However, we believe that we need further explanation of his statement, “The public will be forced to recognize that the U.S. health care system has always rationed care and will continue to do so in the future.”

This unreferenced statement is quite confusing. If he is speaking as an economist, he has used the concept of rationing incorrectly. The competitive forces of supply and demand in a market establish a price at which decisions regarding selling and buying are synchronized or coordinated, and this dynamic is called the rationing function of prices.2 Any willing buyer can purchase a good or service at the market price. When price ceilings are imposed, a shortage of a good or service follows and thus rationing, with an accompanying black market, occurs. We do not believe that there are any Americans who wish to purchase health care and can afford it, yet are unable to obtain it legally. This scenario is quite different from the sugar and gasoline shortages that occurred during World War II.

Does Dr. Ginzberg mean that the providers (including physicians and hospitals) or third-party payers (or both) are not making available the health care that Americans seek? If so, does he mean that a conscious decision has been made by providers not to give this care because it is too expensive? Does he mean that providers are not giving Americans all the services they demand because it has been deemed that some services are not medically necessary? Does he mean that because third-party payers refuse to reimburse providers for services, providers refuse to supply them? Does he mean that the need for health care exceeds the capabilities of our health care system, forcing a triage situation? In any event, an explanation of what he means by “rationing” is needed.

Stephen D. Boren, M.D., M.B.A.
David M. Boren
University of Illinois, Chicago, IL 60612

2 References

1. 1

   Ginzberg E. The uncertain future of managed care. N Engl J Med 1999;340:144-146
   Full Text | Web of Science | Medline

2. 2

   McConnell CR, Brue SL. Economics: principles, problems, and policies. 13th ed. New York: McGraw-Hill, 1996.
   

Author/Editor Response

Dr. Ginzberg replies:

To the Editor: I was trained in economics and wrote my dissertation on the economics of Adam Smith.1 I learned from a close reading of the greatest economist of all time that most markets are characterized by many imperfections, which more often than not make the balancing of demand and supply the exception, not the rule. Furthermore, Adam Smith recognized that lack of income is the principal source of continuing imbalance between what many low-income people need and what they are able to purchase. Many poor people in this and other advanced countries fail to receive as much health care as they need and as their physicians would like to provide for them, because they cannot pay for such care.

Eli Ginzberg, Ph.D.
Columbia University, New York, NY 10027

1 References

1. 1

   Ginzberg E. The house of Adam Smith. New York: Columbia University Press, 1934.
   

Citing Articles (1)

Citing Articles

1. 1

   Barbara J. Russell. (2002) Health-Care Rationing: Critical Features, Ordinary Language, and Meaning. The Journal of Law, Medicine & Ethics 30:1, 82-87
   CrossRef