Rationing health care: preparing for a new era.

As the American health care system struggles to provide universal access to quality care at an acceptable price, many planners focus on rationing as the only way to make available the necessary resources. I discuss some of the ethical, economic, and political issues that relate to health care rationing. The four important questions to consider when examining a rationing plan are: (1) Who acts as the gatekeeper? (2) What kinds of goods or services are rationed? (3) What happens to the money and resources that are saved by rationing? (4) Does the system provide a safety valve for the well-to-do? This article examines two prototypical rationing systems--the British system and the Oregon plan--and answers these four questions for both systems. Because of the absence of an efficient market economy in health care and the certainty of resource constraints, rationing is inevitable in American health care. The primary issues are whether rationing will be done implicitly or explicitly and whether it will be based primarily on ability to pay (as in the present system) or on comparative judgments about the costs and benefits of medical interventions.