Rationing is the price we must pay for our creative success. It is the ugly child of the marriage of our ingenuity and our egalitarianism.
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"We don't want rationing!" goes a choir of angry voices in the health reform debate. Yet, when we are strictly honest with ourselves, we must admit that, as a society, we already ration. We ration whenever we make choices among the claims of individuals who are competing for scarce resources. Government, mainly through Medicaid and Medicare, pays for approximately 50% of the cost of U.S. health care. People may scream about "socialized medicine," but right now half of our health care in America is "socialized health care." Having undertaken to fund some health care, public policy must be accountable for the consequences of the decision to cover some Americans and not cover others. It is thus clear that the United States denies more health care to more people than any other developed nation. We win the rationing Olympics.

The United States now has the worst form of rationing. We ration people by leaving them out of the system. We tell each other that this is indirect rationing, and apparently we find this morally easier to accept than direct rationing. A sin of omission is easier to live with than a sin of commission. But it is rationing in its cruelest form: the Institute of Medicine estimates that 20,000 Americans die each and every year simply because they lack health coverage.

Let me present a more positive case for rationing. I suggest that a society will not start to maximize its health case access and quality until it fully confronts the issues involved in rationing. It is my passionate belief that we can all have better health care through rationing.

Over the last 40 years the cost of health care has risen from 6% of our Gross National Product to 17%. Most thoughtful health care providers now recognize that the genius of American medicine has invented more health care than we can afford to deliver to everyone. Our medical practice patterns, our medical ethics and our public expectations in health care have been formed during a time when health care costs have been growing at the unsustainable rate of 2 and 1/2 times the rate of inflation. No item in a public or private budget can grow forever at 2 and 1/2 times the rate of inflation; inevitably it must be reduced to no more than the rate of inflation or health care would crowd out all other public and private spending.

No modern society can afford to give to each of its citizens all the health care that is "beneficial." The health care system can no more afford to do everything "beneficial" for every patient than the education system can do everything "beneficial" for every student, or the police department can do everything "beneficial" for every citizen. We are delivering, and the public is expecting, more medicine than we can possibly afford to sustain.

Medical need is an infinitely expandable concept. There is always one more marginal procedure that can be done. There is no end to the medical and surgical treatments that a technologically sophisticated and advanced society can give to aging bodies. It is hard -- but necessary -- to change our thinking after years of "blank check" medicine.

It does little justice to this great country to avoid the rationing issue. The search for the health care system that does not ration, like the search for the chocolate sundae diet, is futile and demeaning. Increasing the efficiency of the existing system and ending fraud and waste, alone, will not come close to solving our volcanically growing health care costs. Rationing is the price we must pay for our creative success. It is the ugly child of the marriage of our ingenuity and our egalitarianism. It is increasingly obvious that the genius of American medicine has outpaced our ability to pay. As one expert, Laurene Graig, put it:

Modern men and women of medicine now have the capability to spend unlimited resources in heroic and sometimes vain attempts to extend life ... such changes pose a serious dilemma to society. A dilemma so new that neither our social, legal, and religious institutions, nor our health care providers or consumers have developed a satisfactory way of coping. How do we as a nation balance our beliefs in the individual choice and values in health care against our community priorities and resources?

We must confront this hard reality: All nations ration -- some by price, some by queuing, and some by setting priorities. I believe a nation does not maximize its health care until it starts to ask the hard question: How can we prioritize our expenditures to buy the most health care for the most people? We should not apologize for rationing; we should promote it and advance it. We cannot explore the "opportunity costs" of limited dollars unless we admit that we cannot pay for everything for everyone and spend our limited money where it will do the most good. In a world of public policy, we cannot say "yes" unless we say "no." It is an inevitable dialogue, and we ought to make a virtue out of necessity.

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