page_title: Healthcare rationing in the United States
section_title: By comparative effectiveness research
hierarchical_section_title: Healthcare rationing in the United States / Methods used / By comparative effectiveness research
caption_attribution_description: English: U.S. Medicare spending per capita Explanation Research by The Dartmouth Institute for Health Policy and Clinical Practice in the Dartmouth Atlas showed that in 2006, Medicare spending varied significantly by state. Other research quoted by the CEA Report indicated that up to 30% of Medicare costs could be saved if the middle- and high-cost states spent at the level of the lower-cost states.[1] Bear in mind that this is a Medicare comparison, so all the persons in the population analyzed are over 65. References ↑ White House Council of Economic Advisors (CEA)-The Economic Case for Health Care Reform-June 2009-Page 19
context_page_description: Healthcare rationing in the United States exists in various forms. Access to private health insurance is rationed on price and ability to pay. Those unable to afford a health insurance policy are unable to acquire a private plan except by employer-provided and other job-attached coverage, and insurance companies sometimes pre-screen applicants for pre-existing medical conditions. Applicants with such conditions may be declined cover or pay higher premiums and/or have extra conditions imposed such as a waiting period.
  The poor are given access to Medicaid, which is restricted by income and asset limits by means-testing, and other federal and state eligibility regulations apply. Health maintenance organizations, which are common among the rest of the population, restrict access to treatment by financial and clinical access limits. Those 65 and older and a few others also qualify for Medicare, but it also has many restrictions.
  In the media and in academia, some have advocated explicit healthcare rationing to limit the cost of Medicare and Medicaid. They argue that a proper rationing mechanism would be more equitable and cost-effective.
context_section_description: Several treatment alternatives may be available for a given medical condition, with significantly different costs but no statistical difference in outcome. Such scenarios offer the opportunity to maintain or improve the quality of care while significantly reducing costs through comparative effectiveness research. Writing in the New York Times, David Leonhardt described how the cost of treating the most common form of early-stage, slow-growing prostate cancer ranges from an average of $2,400 (watchful waiting to see if the condition deteriorates) to as high as $100,000 (radiation beam therapy): 
  Some doctors swear by one treatment, others by another. But no one really knows which is best. Rigorous research has been scant. Above all, no serious study has found that the high-technology treatments do better at keeping men healthy and alive. Most die of something else before prostate cancer becomes a problem.
  According to economist Peter A. Diamond and research cited by the Congressional Budget Office (CBO), the cost of healthcare per person in the US also varies significantly by geography and medical center, with little or no statistical difference in outcome:
  Although the Mayo Clinic scores above the other two [in terms of quality of outcome], its cost per beneficiary for Medicare clients in the last six months of life ($26,330) is nearly half that at the UCLA Medical Center ($50,522) and significantly lower than the cost at Massachusetts General Hospital ($40,181)...The American taxpayer is financing these large differences in costs, but we have little evidence of what benefit we receive in exchange.
  Comparative effectiveness research has shown that significant cost reductions are possible. Office of Management and Budget (OMB) Director Peter Orszag stated: "Nearly thirty percent of Medicare's costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level of low-cost areas."
  President Obama has provided more than $1 billion in the 2009 stimulus package to jumpstart Comparative Effectiveness Research (CER) and to finance a federal CER advisory council to implement that idea. Economist Martin Feldstein wrote in the Wall Street Journal, "Comparative effectiveness could become the vehicle for deciding whether each method of treatment provides enough of an improvement in health care to justify its cost."
caption: Medicare spending per person varied significantly across states in 2006
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