One of the most critical questions about health care reform is the issue of rationing. To be clear about it, any and all approaches to health care incorporate some mechanism for rationing. The rationing mechanism may be explicit or not, but resources are not infinite so there has to be some way to manage the demand on the system.

Our current system provides rationing in several ways, but the most common way is through the use of a primary care physician as a gatekeeper. Insurance companies depend on the gatekeeper to deflect requests that are of questionable value or excessive cost. Insurance companies can also deny coverage for various procedures. People can appeal coverage decisions via several channels including the insurer themselves, government regulators, and the courts.

We also have another rationing system. There are many procedures that are not typically covered by health insurance. These include orthodontics, cosmetic surgery, vision correction, massage, chiropractic, and alternative medicine. Consumption of these services is rationed by the individual's decision of whether or not to pay for them.

Other systems accomplish rationing via wait times, explicit policies, gatekeepers, and other mechanisms.

Rationing is necessary, and all health care systems have some rationing mechanisms built in. Any claim to the contrary is specious. It's worth looking at any and all proposals to determine how rationing works - who makes initial decisions, and what appeal process exists.

Since no system can provide every desired service to everyone, it eventually boils down to someone who has to decide "I will pay for this" and "I will not pay for that". If we are to look at health care reform a very important question is this: who makes those decisions, and on what basis? Maybe even more fundamentally, what are the desired characteristics of a rationing system?

These are certainly good topics for discussion, and in my opinion no effort should be made to change health care without at least some attempt to answer these questions.

Never being bashful about controversy, let me suggest a philosophical starting point:

As much as possible, each person should have the freedom to make their own decisions.

With freedom comes responsibility. The freedom to make your own decisions comes with responsibility for the consequences of those decisions. For health care, part of that responsibility is paying for what you choose to use. This sounds draconian, perhaps because we've grown so accustomed to not seeing the cost of the services that we consume. The fact is that on average we are paying for the services that we use - it's just hidden from sight.

An argument against this approach is the financial consequences of serious medical problems. With health care as in other areas, there is the possibility that some unforeseeable or unlikely disaster could happen and cause financial hardship or ruin. The classic solution for this problem is insurance. We routinely carry insurance to protect us from the financial impact of fires, accidents, and even death. In every case, we decide how much coverage we want when we sign up for the policy. The insurance company is paying, but the rationing decision is made by the individual when they buy the policy.

In my opinion, there's no morally defensible way that you can have complete freedom to decide what you want to consume and then expect someone else to pay for it.

This approach doesn't exclude the issue of providing for charitable care. As a society, we can and probably should decide on a level of medical care that we are prepared to provide for those who are not able to meet their own needs. However, the people making this decision are the same people paying for it.