All healthcare systems involve some form of rationing. This is an inescapable reality that arises from the fact that healthcare is not an abstract right, it is a service that must be provided from a limited supply of resources.
Different system use different criteria upon which to make rationing decisions. Sometimes these are explicit, as in the Oregon Medicaid system, and sometimes they are inherent, such as the Canadian practice of rationing by queues. In the United States, there is a patchwork of rationing, varying by region of the country, medical condition of the patient, and socio-economic factors.
Reform of our healthcare system should start with selecting and designing an appropriate rationing criterion. As a foundational step, it should begin by constraining the definition of "healthcare." It would be next to impossible to design and implement a viable healthcare system if it includes practices of limited application and dubious merit. The first step in overhauling healthcare should thus be to define healthcare as "those practices and interventions that have been shown by rigorous scientific study to have a cost-effective benefit in management of acute and chronic health conditions." For purposes of this definition, "cost effective" would mean the amount of therapeutic benefit per unit of resources expended. Cost-effectiveness would be determined by market mechanisms; i.e. competition among various therapies with those yielding the most benefit per unit cost survivng, and those
This approach would be exactly counter to present practice, which is to take an entitlement and expand the definition of it to ensure that it not so much grows as metastasizes.