In the last few years, the U.S. health care system has seemingly been gripped by “back to the nineties” fever. Back then, we had a Democratic president working to reform the health care system. Experts from across this system were promoting the importance of controlling health care costs; the growth of health care expenditures even slowed considerably around that time. Now we have a Democratic president who not only tried to reform the health care system but also managed to pass a complex health care law. As in the nineties, experts have been promoting the importance of controlling health care costs, and health care expenditures have even slowed over the past four years.
But for those working at the intersection of health care policy and ethics, there is a notable change in professional debates about how to better control health care costs. Discussion of health care rationing, which was hotly debated in the nineties, has become much more muted. The decline of rationing debates may reflect shifting emphases in health care policy. In the nineties, managed care companies (which the Clintons hoped to promote in their reform efforts) were capitating medical care, paying health care providers lump sums to care for panels of patients, thereby giving them a financial incentive to withhold medical care in order to hold on to some of that money. Such a strong incentive to withhold care inevitably sparked rationing fears.1 By contrast, the Affordable Care Act promotes accountable care organizations,2 which for the most part function on an old-fashioned fee-for-service basis, with modest incentives to contain costs while demonstrating high-quality care.
The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.