That's almost certainly the future of healthcare and we might as well face it. Darshak Sanghavi sees how the Massachusetts's heathcare reform has panned out. An important point:

Why does a progressive state like Massachusetts strong-arm many individuals and businesses into buying expensive insurance plans that don't encourage actual visits to the doctor and hospital? According to the Kaiser Family Foundation, the average person consumes more than $5,000 per year in health care resources. No matter how you slice it, some entitygovernment, business, or the individualowes a boatload of cash for medical expenses.

From his closing:

The lesson of Massachusetts is that really good health care is also really expensive.

The concern isn't who writes the checks or who writes the bills. The real question is who makes the tough decisions about the limits of the checks and billsin other words, who ultimately rations the money. Not everybody can have everything, and the sooner we admit that, the sooner our health care debate will get realistic.

In the haphazard Massachusetts plan, rationing fell to individuals, who then skimped on important prescriptions and routine visits. Gawande would leave rationing to properly incentivized doctors, but we have no data about whether this can be done widely. Others advocate for bodies like the Medicare Payment Advisory Commission (an impartial medical Federal Reserve Board), which can make the hard calls to promote and limit certain kinds of medical care. Britain, for example, has a national institute that makes precisely these decisions, like limiting drug-eluting stents for coronary artery disease and certain pricey drugs for kidney cancer. And health insurance executives here are again talking about "capitation," or fixed global budgets in which a group of health providers gets fixed monthly fees to handle all of a person's health needs.

In the meantime, one thing is sure: Without a smart plan to ration our resources wellthat is, stick to a budgetand improve health, simply mandating that employers and individuals buy health insurance will only worsen the mess.

We want to hear what you think about this article. Submit a letter to the editor or write to