Regulatory rationing: a solution to health care resource allocation.

Despite all the recent controversy, rationing has always been a part of medical decision making. Figure I presents a spectrum of ways in which health care can be rationed. Whether imposed by a market system in which price determines access, a triage system where care is distributed on the basis of need defined largely by the medical community, or a queue system in which time and the waiting process become the major rationing device, medical resources have always been distributed according to criteria that contain varying degrees of subjectivity. In almost all instances, rationing criteria are grounded in a particular value context that results in an inequitable distribution of resources based on social as well as strictly medical considerations. In addition to illustrating the range of rationing options for health care, Figure I introduces yet another complexion in defining the concept. Some forms of rationing infer or necessitate government involvement, either direct or indirect, while others fail to distinguish between private and public sector choices. This distinction is critical to a clarification of how current health care options differ from past ones. Less explicit forms of rationing toward the top of the figure are no longer sufficient to resolve health care dilemmas in this era. As a result, we are now witnessing a shift toward the bottom end of the spectrum, possibly culminating in a central role for the government in the rationing of increasingly scarce medical resources. Although explicit rationing under the authority of the government is but one form of rationing, there appear to be many forces that, concurrently, are moving American society in that direction. At the same time, however, explicit public rationing is feared by some observers, who suggest that rationing is unnecessary or an anathema to be avoided at all costs. 1