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Until now, our culture of no limits has made it unnecessary-or impossible-to agree on the purpose of healthcare services. But as soon as we admit that there are limits to what we can spend, we have to specify that purpose. We have to keep this definition in mind as we decide on the scope of activities that our limited healthcare dollar will cover.

I approach this problem by defining the purpose of healthcare services as I see it, then considering the implications of this definition as it relates to rationing.

The purpose of healthcare services is to maintain or restore the individual's health when possible or to optimize functional capacity, control symptoms, and compensate for restrictions when a disease or disability cannot be cured or prevented.

What this definition does

This definition implies that the overriding goals of the healthcare system are to prevent and treat disease and to provide individuals who cannot be rendered disease-free or disability-free with their best opportunity to enjoy the rewards of life. It charges the healthcare system with a public health task (searching for ways to prevent and treat diseases that afflict humans) and with an individual health task (to optimize the health and functional status of individuals, whether or not they have diseases that can be "cured.")

What this definition does not do

Many people would consider this statement subversive, for it removes from the province of healthcare services activities they would want to include: It does not require doctors to prolong life as long as possible, whatever the cost in dollars or in suffering; it does not require altering the normal progression of life (for example, halting the aging process); it does not charge the healthcare system with seeking out or administering treatments that enhance the lives of people in the absence of disease or disability (for example, face-lift surgery or hair transplants). This definition acknowledges limits to what the healthcare system can do and to what it should be expected to do.

Many would like to see a broader definition. For instance, some would require the healthcare system to provide individuals with physical, mental, and social wellbeing.

Such an inclusive definition encourages the medicalization of society, whereby various conditions not traditionally considered diseases are being redefined as such. Medicalization presents a real difficulty for us in the context of open rationing. Some people classify shyness as an illness that reduces a person's capacity for social wellbeing, for example. But do we really want people with cancer to have to compete with the shy for healthcare resources? Under a system of open rationing, we ought to limit the scope of healthcare services to real, honest-to-goodness diseases and disabilities and rescind the list of boutique illnesses our society has created in recent years.

You may or may not agree with the specifics of my proposed definition, and that's fine. But before we can begin to devise an equitable system of open rationing, we have to define the scope of healthcare services.

Principle 2 - There must be open competition for resources between healthcare services and all the other services society provides

Having defined the purpose of healthcare services, we need to prioritize that purpose in relation to all the other services society is expected to provide. These include national defense, the interstate highway system, education, the criminal justice system, garbage collection, and others. Those who think in terms of the no limits paradigm for healthcare can have trouble with the idea that healthcare has to compete with the stealth bomber for our limited public resources. But to the extent that healthcare will be publicly funded under our new system, that is the way it is; and a fair system of open rationing forces us to recognize this.

We should prioritize services through an open budgetary process, considering dollars allotted to healthcare in relation to all other necessary expenditures. We can increase healthcare benefits by allotting more dollars to healthcare, but only by reducing some other benefit-increasing the class sizes in elementary schools, for example. Having to consciously make such trade-offs may cause us to reevaluate all our priorities.

Principle 3 - As much as possible, rationing decisions should be left to the patients affected by those decisions

Rationing decisions will be fairer and more acceptable if they are made by patients themselves instead of imposed (through coercion of physicians) by a distant bureaucracy.

Not long ago, individual patients and doctors made spending decisions. Quadrant IV healthcare insulated both doctors and patients from the cost of their healthcare decisions. There was no incentive for patients to forego the most expensive testing or the newest therapy available, whatever the cost and no matter how small the expected marginal benefit.

A system of open rationing should remedy this disconnect by establishing incentives for patients to take the cost of medical services into account when making decisions about their own healthcare. The more cost-efficient the decisions patients make on their own behalf, the less rationing will have to be forced by a third party.

One way to provide such incentives is to integrate a modified form of Health Savings Accounts (HSAs) into our rationing system. HSAs provide a strong incentive for individuals to reduce nonessential healthcare spending and thus have the potential to reduce the overall level of imposed rationing that will be necessary. Later in this chapter I show how these modified HSAs would work for all Americans in a proposed new model for healthcare.

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