Originally uploaded at SSRN.


This essay offers an explanation for the United States' continued resistance to universal health care as grounded in two taboos: taxation and rationing. Even we were willing to pay more in taxes to directly subsidize the cost of medical care for those in need, rather than our current system of indirect subsidization through private insurance risk-pooling and cost-shifting, we still would face the unavoidable reality of resource limitations. Attempts to limit resource consumption, however, have been strongly opposed, as evidenced by the "death panels" controversy. Governor Palin's grossly erroneous characterization of the Patient Protection and Affordable Care Act (ACA) rendered one ACA provision, regarding end-of-life planning, impassable and another, regarding comparative effectiveness research, largely impotent. Even these patient-centered, autonomy-favoring provisions could not be fully enacted once tainted by the suggestion that they would result in rationing of health care. Meaningful health reform, whether private-market-based or single-payor, will inevitably have to decide what to pay for and for whom.