Muddling Through Elegantly

Finding the Proper Balance in Rationing

In Mechanic's original article published in Health Affairs in 1997, the author writes:

"The increasing tensions between the possibilities of medical intervention and the need for economic constraints place the rationing of health care squarely on the agendas of most nations. Although medical care has always been rationed by the location and availability of practitioners and facilities and by the ability to pay for care, we are clearly entering a new era in which it is more difficult to balance the possibilities of medicine and public expectations against the willingness to finance them."

In 2007, Mechanic's article was selected for inclusion in a special issue of Health Affairs. The editor notes:

The tension between access and excess in the U.S. health system—between the bountiful coverage that many enjoy and an unsustainable rate of cost growth—has not abated in the decade following David Mechanic's elegant discourse on rationing. But Mechanic's essay was published when friction was peaking between payers on one side and providers and consumers on the other. Oregon's experiment in explicit rationing had demonstrated the extreme political sensitivity of the concept, and the burgeoning reaction against implicit rationing by private plans would soon show that the market, too, was prepared to punish severely anyone who stood in the way of the insured consumer's demand for services.

Indeed, it was difficult in 1997 to find anyone who could discuss the subject with equanimity and good sense. For these qualities, and the depth of his insights, Mechanic's essay is as relevant and useful in 2007 as it was when it was first published.