Using a broad definition of
rationing to include any mechanism that allocates health
care resources, this Issue Brief examines the
health care system along two dimensions: what differences
exist in the utilization of health care services and who
makes the decisions that create these differences. It
finds that similar people are given different treatments
as a result of decisions made by others.
Proposals to reform the health care
system implicitly or explicitly alter the way decisions
are made on how health care services are rationed. The
current system allocates health care services in a number
of ways: by ability to pay, by physicians and hospitals,
and by government decree. Understanding rationing as it
currently exists is critical to making informed choices
on the future of the health care delivery system.
The U.S. health care delivery
system has a number of characteristics that limit the
market's ability to allocate resources efficiently or
equitably. Income is one of the most important
determinants in rationing health care services, but even
individuals with relatively high incomes face some
constraints on their choice of health plans.
There are large differences in the
way health care is rationed by type of health insurance
coverage, characteristics of the local health care
market, provider type, and employment situation.
There are many decision makers in
the health care delivery system, but decisions on the
consumption of health care services—unlike decisions in
other markets—are not primarily being made by the
consumers of these services. Health care cost inflation
has led to changes in the way health care is financed in
both the public and private sectors. As a result, the
choices available to consumers are constrained not only
by income but also by employers, insurers, providers, and
government regulators.
Much of the debate on health care
reform has centered on the notion that efforts to
increase access to care and control costs may lead to
health care rationing. However, we are rationing health
care resources in our present health care system. More
appropriately, the debate should focus on the mechanism
for allocating health care resources and the tension
between individual decision making and social objectives.
This Issue Brief provides a basis for that
discussion.
