By Gopal Sreenivasan, PhD

Gopal Sreenivasan, PhDHealth care reform has been debated for decades, but an ailing economy, aging population, and new administration are bringing a renewed sense of urgency to the discussion of how to manage the costs and provision of health care in the United States.

Bioethicist Gopal Sreenivasan, PhD, asserts that a seemingly severe approach -- rationing -- is not only part of a workable solution, but a moral duty.

Most people believe that health care systems should ideally provide citizens who are sick with whatever health-related goods and services they need. While this model may appear at first glance to be the equitable way to meet people’s health care needs, it is not really morally defensible on a national scale.

This is because a nation’s health is not the only important good with a claim to the finite pool of social resources -- there are also education, defense, transportation, and infrastructure, to name just a few others.

The more society allocates to health-related goods and services, the less it can allocate to anything else.

In other words, when access to every medically necessary good and service leads to overspending on health care, a country is forced to underspend on schools, roads, and other critical services. This is incompatible with justice, which forbids robbing Peter to pay Paul.

Countries are therefore morally obligated to observe a strict limit on health care spending. In effect, they must fix a ceiling on their annual health care budgets before knowing the total cost of the medically necessary care required by their population over the year.

By supporting this approach, a nation commits itself to rationing the health care goods and services it provides its citizens.

Building the Case for Rationing

Since rationing means that citizens will be denied some medically necessary care, people are often understandably uncomfortable with this notion. Most don't want to say it's acceptable to withhold health care benefits or to settle for anything less than what is, at least in principle, possible.

It seems uncompassionate, even unfair.

Still, the evidence is clear and mounting that we must set limits on health care expenditures. Already, the United States spends more on health care -- both absolutely and as a percentage of the gross domestic product (GDP) -- than nearly every other country by far.

Even worse, in America, the growth rate of medical spending has consistently surpassed the growth rate of the GDP in recent years.

In fact, the share of the GDP the U.S. spends on health care -- about 16 percent -- is projected to reach nearly 20 percent by 2017. (The average for countries in the Organisation for Economic Co-operation and Development is 9 percent.)

When the percentage of GDP spent on health is rising, that means that health care spending is gobbling up resources that were previously spent on other goods. As long as the growth rate in health care spending outstrips the growth rate in GDP itself, this diversion of resources from other legitimate expenditures only gets worse.

At current growth rates, health care spending will eventually cross the line into claiming resources that should be spent on other goods, no matter where you draw that line. Since it is difficult to defend a more-than-15-percent share of GDP designated for health care, that line may have already been crossed.

Of course, it's hard to suppress the thought that if only we could eliminate all the waste and inefficiency in the health care system, we really could have it all -- and not have to settle for rationing medically necessary services.

Yet while every little bit helps, it's highly unlikely that improving efficiency and eradicating waste would allow us to cover everything, as the "Growth in national health expenditures under various scenarios" chart makes clear.

The three lines represent projections of health spending under different assumptions about possible cost savings. The top line (baseline national health expenditures) projects current growth trends without any cost savings. The "one-time savings scenario" assumes significant initial savings (e.g., from eliminating waste), but no change in the underlying growth trend. The "slowing trend scenario" assumes the reverse: no significant initial savings, but a smaller underlying growth rate.

Even the best-case scenario (slowing trend) has health care spending almost doubling between 2005 and 2015. That is because new technology, rather than waste or inefficiency, is the fundamental driver of growth in health care spending.

Asking the Tough Questions

But how do we decide where to cut costs? The first step is to establish a firm limit on health care spending that is independent of (and less than) what is technically possible to spend on health care, even when spending is restricted to medically necessary services and all waste is eliminated.

However, this does mean accepting that some medically necessary and beneficial services will not be covered, because we cannot reasonably afford it.

The next step is to develop adequate measures of the comparative cost and effectiveness of different effective medical interventions. The goal would be to have a rational and accountable method of deciding which interventions are most worthwhile to cover with a limited budget and which ones, regrettably, must be left out. But this is another topic for another day.

The questions of how to ration health care, and how much care we as a country can reasonably afford to pay for, will not be easy to answer. But accepting rationing as a necessary and moral approach remains the first step toward resolving those questions -- and creating a more just health care system.

Gopal Sreenivasan, PhD, is the Lester Crown University Professor of Ethics and a professor of philosophy in Duke's Trent Center for Bioethics, Humanities, and History of Medicine. His research in bioethics largely focuses on the broad notions of health and justice.

This article was first published in the Winter 2009 edition of DukeMed Magazine.