ZDoggMD on Healthcare Rationing: The Uncomfortable Truth We Won't Discuss

This article discusses ideas from ZDoggMD — Dr. Zubin Damania, MD , Stanford/UCSF-trained internist, founder of the Health 3.0 movement. Full archive: zdoggmd.com | YouTube @zdoggmd

Every healthcare system in the world rations care. The question is not whether to ration, but how. The US rations primarily by ability to pay — those with comprehensive insurance or personal wealth access the full range of available care; those without may receive limited or delayed care for the same conditions. ZDoggMD has named this honestly, which is rarer in US healthcare policy discussions than it should be.

How Different Systems Ration

Universal healthcare systems ration differently: through waiting lists for non-urgent care, through coverage limitations on certain interventions, through formulary restrictions on medications. The UK's NICE (National Institute for Health and Care Excellence) explicitly evaluates cost-effectiveness of treatments and makes coverage recommendations based on a threshold of cost per quality-adjusted life year. This is explicit rationing — transparent, publicly accountable, and evidence-based.

The US, by contrast, practices implicit rationing — coverage varies by insurance plan, income determines what care is accessible, and the decisions are made through thousands of fragmented insurance coverage determinations rather than through transparent public policy. The result: Americans with good insurance have access to care that is unavailable to those without, and the distribution of access correlates strongly with race and income.

The Physician's Role

ZDoggMD argues that physicians need to engage with these policy questions rather than treating them as outside the scope of clinical practice. When a patient can't afford their medication, that is a clinical problem. When prior authorization denies a clinically indicated treatment, the physician is the patient's best advocate. The political and the clinical are not separate.

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