"Rationing" has become a big negative buzzword in the current health care debate. As in, "we don't want any rationing of our medical services." We already have horrible rationing, and anyone who thinks we don't isn't paying attention.

Repeatedly I've heard tales of the rationing present in the Canadian system. Often I've heard the specific example of long waiting lists for joint replacements, or patients being denied knee replacements because of factors like age.

I have had plenty of real-life patients with bad knees and demanding jobs. The following case is an amalgamation of 3 or 4 cases I've seen.

Two patients both have jobs in the housing industry, and both of them need to go up and down ladders. These bad knees make it really hard to go up the ladders. Both have been hit by the lagging construction industry, sharply reduced demand for new homes, and have had to cut back on hours. We'll call them Bob the Builder, and Chris the Constructor.

Bob works for a large company, and has standard private insurance. He got a knee replacement pretty quickly. After recovery, he feels much better. He can't go up the ladders like he used to, but because of the reduced hours, he's working OK at the moment.

Chris is a self-employed small business owner. He used to have 1-3 part time employees, but he doesn't have work for them. I think he used to have insurance, but he had to drop it, because his business is not making any money. He doesn't qualify for Medicaid because of his assets. He's not getting a knee replacement anytime soon. Potentially he could sell his business, and get a job for a company, tough it out on the ladders until he gets insurance, and then get the surgery, but nobody's hiring. It's possible the economy could recover before he is unable to work, and he could get insurance or pay cash for the surgery. Best-case scenario, he gets a knee replacement in a year or two. Worst-case scenario, he never gets the knee replacement, blows through all his assets, ends up on state support with Social Security Disability, Medicare, and Medicaid and (maybe) gets his knee replacement in 2-4 years. By that time, he will probably never re-enter the work-force. Or maybe the worst-case scenario is that he ends up homeless on the street. That happens too.

This is how health care is rationed in this country. In Canada, both Chris and Bob would get knee replacements in say, 3-6 months. I don't want us to end up with an exact copy of the Canadian system.  We spend about 16-18% of our GDP on health care, and Canada spends 9-10%. So we should get something better, because we pay more.

I think it's actually reasonable, at a level of 17% of our GDP, that we could pay for all necessary health care for all Americans. That's a lot of money, and it should go a long way. If an American pays twice as much per capita than a Briton, it stands to reason our product should be twice as good. But health care in the US is currently so inefficient, fails to cover 12% of our citizens.  There need to be major changes in the entire delivery system before we can get the maximum bang for our buck. I suspect this would probably be with a single-payer system,
similar to Canada's. Or we could end up with something closer to Germany's. (It seems to be the country closest to the Democrats' model) That's going to take a concerted effort, and probably a decade or two.

But in the short term I doubt we can provide health care for everybody without some form of rationing. Currently we ration on factors (employment status, size of employer, student status, parental employment status) that make no sense.

P.S.
Most of the current debate is on the "public option." In Germany, 87.5% of people choose the public option. The private insurance companies seem afraid to compete with the U.S. Government, and for good reason: they suck. I can't think of another industry with worse customer service. Large portions of their business model consist of denying or delaying reimbursement for services paid for by their customers. If the Government offered a viable alternative, people would run from the private insurers in droves, and they know it.

P.P.S.
All this assumes that you (like most bloggers and talking heads) consider short waiting lists to be a major health indicator, rather than infant mortality and life expectancy (like most public health experts).