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If I stand back far enough I can ignore the difference. But even moderately up close there is one, and I think it's important. I usually stand, by default, moderately up close.
In my limited experience doctors require pre-approval for nearly everything under Medicaid and Medicare. Before a procedure or test is scheduled, it's got to be approved. Often a schedule will include all sorts of tests and procedures so a doctor will just shrug and say he can't do it. They assume the patient can't pay for it, esp. if they are on Medicaid. With reimbursement rates low, there's not a big incentive for doctors to subsidize care, it wouldn't be a rare occurrence and there's no real monetary ROI. Even though I know they're rationing *dollars*, not health care itself, there's a close enough correlation that to ration dollars is to impose a limit on health care. It's sloppy thinking but good enough.
With my private insurance, claims are submitted. Providers don't usually seek pre-approval. When claims are denied it's usually after the procedure or service is done; how that gets paid varies, from my being charged full price, insurance-company price, or just the co-pay--it's infrequent and there is a monetary ROI in some cases. In any event, that's rationing of disbursements but not rationing of health care: there's not usually a required pre-approval so the linkage between rationing dollars and health care is broken--and since there are levels of service that are up to me to decide, it's not really rationing. In some cases the insurance company does require pre-approval; but it's just the same claims process with the timing a bit offset, so I extend 'denial of claim' to cover that as well. In those cases it is a kind of rationing.
I do refer to the entire insurance company industry as a kind of rationing, since if you don't have health insurance your health care options are limited, usually to just the ER. I believed that ER use correlated with insurance, so that people with insurance were "in the system" and not subject to the same kind of rationing as those outside the system. Recent studies show I was wrong: ER use correlates not with insurance/lack of insurance but with some aspects of SES. Add insurance to a given group and the ER use doesn't significantly change, at least not over the first year or two.
I think some definitions are in order. I think of rationing as neither a negative or positive term. It's a term used when needed, that's all. You have it when there is a ratio-driven distribution of a limited resource that is imposed, if you ignore the black market, pretty much on everybody. Butter to families and steel to manufacturers during WWII, for example. I thought that the 1970's gas "rationing" wasn't a good use of the term, but it did provide some imposed limitation on gasoline distribution. I think of Medicare as rationing because under Medicare everybody's treated the same, per a formula; Medicaid is the same. There's a limited resource--health dollars--and that translates into limited health care available. You don't pay for different levels of care within those systems. (Even if there if there private supplemental policies.)
Health insurance is a kind of rationing in the sense that it's a way of distributing merchandise or services and those services are limited in quantity. We use the same kind for food, shelter, transportation, clothing, and even, to some extent, education, but those aren't really limited. We don't think of the fact that poor people buy lesser-cost food or less food as rationing, simply because even poor people often have some discretion. It's not usually an arbitrary distribution. I slighted health insurance for a decade because I could afford to pay the doctors and used the money saved on housing and food. I know a family where everybody has Blackberries and cell phones, they rent a 2400 sq ft house, but they have no health insurance, eat crappy food, and even let their car insurance lapse. Their choice. For them, health insurance is a commodity they could afford but they choose not to: This isn't rationing any more than we have food or housing rationing.
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