All Rationing Is Self-Rationing

Suzy Khimm writes that "Some Republicans are now casting Rep. Paul Ryan's budget plan as a form of 'self-rationing' that would place such decisions in the hands of private citizens, rather than cold-hearted bureaucrats."

What I never understand about this is that all "rationing" is self-rationing. If we have a single-payer system that's only willing to pay for certain services, then citizens are still free to pay out of pocket for other things. The fact that Medicare won't pay for a MacBook Air doesn't mean that grandpa can't buy a MacBook Air, it just means he has to spend his own money on it if he wants one. Cato's Michael Tanner tells Politico that "The question's going to be, is that decision going to be made by government and imposed top down under the current system? Ryan wants to shift that responsibility to individuals and from the bottom up."

But this isn't the question at all. Under any conceivable system there are some things that the federal government will pay for, and other things people will buy on their own.

I think conservatives have gotten themselves tangled up in this web because they don't understand that their own critique of big government rationing is a metaphor. Sometimes rationing really happens. During World War II, governments suffered from a lot of commodity shortages, and for the sake of equity chose to distribute the scarce commodities via rationing—hard caps on the quantity anyone is allowed to buy with his or her own money—rather than prices. Contemporary American cities often ration on-street parking. Meter rates are generally low, and resulting shortages are dealt with via rules limiting the maximum quantity of parking time you can purchase. This is real rationing, and it's very inefficient. In theory you could institute a strict licensing regime on health care services, but nobody's proposing to do so and there's certainly no fiscal policy need to do so. What's being proposed is to try to deploy evidence about the effectiveness of different treatments to limit what Medicare will pay for, leaving people free to pay for it themselves if they want to. Conservatives who don't like this idea chose to metaphorically label this "rationing" but it's no different from what they themselves are proposing to do. They just want to add a new layer of rent-seeking profiteers into the mix.