You should see some of the proposed rules. Pre-authorization will start to use a medical language called CQL and there will be literally thousands of queries EHRs will need to implement to ensure their customers can get the care they need.
If you want to see true rationing, look to the UK (especially) or Canada (less so) where I know plenty of people who have to wait over a year to see a specialist even after doctor referral.
Meanwhile, my parents in the US at a hospital get a CT scan, MRI 'just in case' immediately (or close-to for the MRI) and pay nothing for it.
I live in U.S. and know people on ACA Marketplace plans, employer HDHP, Medicaid, Medicare, Medicare Advantage, people who are uninsured, people who are overinsured, and people who have crazy expensive fly-me-out-of-the-jungle emergency plans (one who actually used it in the U.S.).
I have never heard any of them get an MRI or CT scan same day "just in case." And for the one who got an MRI close to same day for stroke symptoms, it wasn't free. (And even in that case, the earliest appointment with the specialist to assess the MRI was nearly a month later.)
Someone getting their first colonoscopy had an appointment two months out.
Someone getting shoulder surgery four months out.
A person on Medicaid with Stage 4 cancer waiting a week and a half for a fentanyl patch because the pharmacy couldn't get approval from the Medicaid subcontractor for whatever reason.
People from the U.S. who post on HN: please tell HN which is more common:
* my stories
* your parents getting free MRIs and CT scans "just in case"
In the UK, you can pay more (say 30%-40% the cost of a US health insurance plan), get treated like royalty in private care, skip all the lines for specialists, still be covered by the NHS to pay 0 for anything catastrophic, and still never get a bill in the mail from anyone.
It's not an either/or situation. The US has the least efficient healthcare system of any country in the world. It provides less treatment per dollar than anywhere else. You can provide universal basic coverage and still provide luxury insurance plans.
I bet we could cut down NHS waiting lists a fair bit if we arbitrarily decided that ~10% of the population were no longer entitled to a wide range of non-emergency treatments.
Provider availability is non-uniform across the US.
Comparing getting imaging work done to actually seeing a specialist is comparing apples to oranges. They're both healthcare related things but are massively different.
There's tons of imaging clinics staffed by people who only needed an associates degree from a community college, radiologists work remotely all over the place spending little time on each patient and writing a report. Overall its really cheap and easy to build and staff an imaging location.
Seeing a specialist requires actually going to the doctor in person, that doctor had to spend many many many more years and limited spots for an education, and probably only sees patients in clinic a few days of the week. You'll have a whole staff of nurses & PAs (who quite probably had more education than the rad tech) and office staff to support the small handful of specialists.
As a personal example, I had an issue with my knee, locking up from time to time bending with weight on it. I looked up kinesologists in my area covered under my insurance. Dozens within a short drive, awesome. Calling up, "sorry, we're not taking new patients", "we can see you in four months", etc. A few months go by, I finally get in to see the doctor. He has me do some motions, asks me a lot of questions, takes a quick x-ray in the clinic, recommends I go get an MRI and come back. I am able to find an MRI clinic that's covered and can get the imaging done that same day. However, its several more weeks until I can see the doctor again to actually review the radiologists notes. I finally go back, the doctor recommends surgery, a prior authorization gets filed. We wait. We wait. Denial, no MRI, imaging required to determine medical necessity. Huh, they paid the bill, didn't they wonder what the MRI said? Resubmit. We wait. Denial, MRI was inconclusive (it wasn't). Resubmit. We wait. Denial, physical therapy is recommended instead (except the thing they call out as a reason to have surgery is verbatim what the radiologist notes say). Resubmit. We wait. Denial, same response. Its now been almost a year of intense joint pain every time I crouch down, walking is starting to be difficult. I'm in a brace and crutches and the pain is getting worse. I finally just wait at the clinic all day, we spend hours and hours on the phone with the insurance company to try and get an approval over the phone directly. I finally get approval, and manage to get in for surgery several weeks later. I have the surgery in the morning, and I'm back to walking without any pain and without crutches or the brace by lunch.
And in the end, after the surgery, the insurance company complains they shouldn't have covered the procedure because supposedly I didn't have an MRI of that knee. Idiots.
This is just one of several shitty stories I have of dealing with health insurance companies. Multiple over the years.
And that's on the insurance side, not even the care side of things! One time, while waiting multiple hours in an ER complaining about becoming massively lightheaded and weak and barely able to sit, I finally passed out and fell on the floor out of my seat. The shock of hitting the floor woke me up a bit, and the first thing I heard was "sir, you're not allowed to lay on the floor, stand up." Uh, I would if I could!
All in all it took over a year of joint pain before I managed to get surgery to fix my knee, all because the insurance company was rationing care. A year I won't have playing with my toddler at the time (I couldn't easily crouch down to play and expect to stand back up easily). Arguments of "bUt RaTioNinG!" ring extremely hollow to my ears. We already have rationing in America, you just haven't experienced it yet.
