The current Health Care Debate answers one of the critical needs in this country: how to provide protection to everyone (or nearly everyone). But there is another need: how to contain costs and make health care more efficient. We’re hearing more about how to provide health care to some of the 47 million people in this country without health insurance, but very little about how to make the system more efficient. Let me tackle these two separate issues one at a time.

The figure of 47 million without insurance comes from the census department and is from 2008. That translates to 20% of the US population under 65. There is nearly universal coverage for the population over 65 because of Medicare. Most Americans get health insurance from their work, or the work of someone in their household. Unfortunately that excludes people who are under 65 and not working, people who own their own business, and people who are not eligible to receive health insurance from their employers. These people daily live with the awareness that an accident or serious illness can have catastrophic effects. It’s true that if you are uninsured and are injured, the emergency room of any hospital is required to treat you regardless of ability to pay, but that’s a long way away from being cured. According to the Emergency Medical Treatment and Active Labor Act (EMTALA) the hospital is required to treat a life threatening emergency until you are stable or can be transported somewhere else you can be treated. They are not required to treat a serious, but not life threatening, emergency and can “release” you once you are stable even if you life was in danger when you came in.

Now, whenever we liberals talk about expanding health coverage conservatives scream that government run health care would be a disaster. But the funny thing is that since 1966 we’ve had virtually universal, government run health care for those 65 or older. It’s called Medicare. I work with the elderly and to a person they like how Medicare is run. When you turn 65 you are eligible to enroll in Medicare, but not required. You are free to not enroll and find health insurance on your own. Funny that I don’t know anybody who has done that. It’s also funny that we have universal health care for the elderly (who vote in high numbers) but not children (who can’t vote).

But this misses my main point. We are not dealing with is the outrageous cost of health care and how poorly we ration it. Do not be fooled: we currently ration health care but we do it by coverage. If two 40 year old men are diagnosed with Type 2 Diabetes (formally called “Adult Onset Diabetes”) and only one of them has health insurance, their lives will become dramatically different. The one with health insurance almost certainly has access to medication (either oral or injectable), counseling to change your lifestyle, and methods to monitor your blood sugar level. The one without has none of this. The one without health insurance is looking at a dramatically shorter lifespan with the added benefits of possible blindness and gangrene in your feet.

The hard, cold reality is this: no matter what we do, we won’t ever be able to have everything we want as we want it as soon as we want it. We as a nation have to decide who will not receive all they want. Currently we ration by ability to pay (either privately or through insurance). I don’t believe this is the best way.

The further hard, cold reality is that no matter what we do, the death rate is still the same: one per person. We are all going to die one day and all the health care in the world isn’t going to stop that. The purpose of health care is not to allow us to live forever, but to allow us to live a good quality of life for as long as is practical. That said, there really does come a point where additional health care dollars are not doing that. For example, if a 95 year old man with terminal prostate cancer wishes to have aggressive chemotherapy treatment it probably doesn’t make sense. The chemo is likely to be unsuccessful, and even if it does stop the cancer, he is likely to be much sicker from the chemo. Even if the chemo is successful and doesn’t lead to additional bad side effects, he is still a 95 year old man who will likely die of something else within the next few years.

Under the current system, if he (or his family) demands aggressive treatment he will likely get it. His primary doctor can refuse to allow the chemotherapy but most doctors will go along with the patient or family if they are insistent enough. Also, if his heart stops beating (for any reason) the local paramedics will try through CPR to get it going again. Essentially there is little in the current system that will tell him it’s time to go. These are resources that are not being used to help people who will. The chemotherapy the 95 year old man receives takes away from the ability to provide preventative medicine for children and the poor. Unfortunately at this time there is nobody who is able to say no to the 95 year old man.

This isn’t about death panels. It is about recognizing that limited health care resources need to be allocated where they will do the most good for the most people. My father in law is 90 years old and is in good health. Recently I overhead a conversation he was having with a few friends. He was explaining that if there was a procedure that he needed and a 30 year old man needed the same procedure, the younger man should get it even if the younger man cannot pay for it. His friends were astonished and basically said that the 90 year old is entitled to whatever he can afford, and if the younger man can’t afford it, well that’s life. Frankly, I hope when I’m 90 I’ll have the same insight as my father in law.

At some point this discussion has to be part of our health care debate.