Treatment of Coronary Artery Disease: What Does Rationing Do?

Henry J. Aaron

Providing all beneficial care to those who need it is rapidly becoming unaffordable, even for a nation as rich as the United States. The highly decentralized U.S. payment system is unique in its lack of effective levers for limiting health care spending, and managed care has largely been ineffective. A different solution, considered extreme by many in the United States, is rationing.

The need to ration healthcare has long been a reality in the United Kingdom where healthcare spending must be covered by an annual budget accounting for only 7.6 percent of GDP—about half the U.S. share. These decisions are perhaps most difficult in regards to treatment of conditions that are literally matters of life or death, such as coronary artery disease.

This brief examines reasons for the differences in treatment and outcomes in the United States and Britain, and discusses the difficulty of rationing care in the United States, where a unique payment system now uses income from those with health insurance to cover the medical costs of the uninsured.

Policy Brief # 148

A major national debate in the United States about health care rationing is inescapable. The debate will be driven principally by rapidly rising per capita health care spending resulting primarily from advancing technology and population aging. To make highly beneficial and cost effective care available to all who stand to benefit from it, it will be necessary to curb spending on high-cost, low-benefit care. But achieving such economies is fraught with analytically difficult and emotionally wrenching choices. In a previous policy brief, I explained how the British have dealt with such choices in the case of diagnostic radiology and why their decisions provide us a window on the problems we will confront. This policy brief will extend that comparison to treatment of heart disease. It will conclude by explaining why the elimination of low-benefit high-cost care will require the extension of health insurance coverage to nearly all Americans.

Heart Disease: The Number-One Killer

Coronary artery disease causes more deaths in both the United States and Great Britain than does any other illness. The most common surgical treatments for heart disease—coronary bypass grafts and angioplasty—are performed more than four times as often in the United States than in Great Britain. Physicians on both sides of the Atlantic regard this difference as not medically justified. Mortality from heart disease, once higher in the United States, is now lower than in Great Britain. In addition, British patients may live with more pain and limitations from coronary disease than do U.S. patients. Although British patients are reportedly more stoic and less demanding than their U.S. counterparts, biology has not identified a gene coding for stiff upper lips. Stoical attitudes emerge in part to cope with inescapable medical constraints imposed by fiscal reality. If excessively rapid growth of health care spending forces the United States to curtail outlays, limits will emerge here similar to those found elsewhere.

View full policy brief — (PDF – 1301KB)