Yet, says Sisk, "in the U.S. we rarely do that. Rationing is a bad word." Thus the implicit rationing of managed care, a surreptitious chipping and whittling that takes place behind the scenes. Ironically, HMOs the focal point of much of today's frustrations with health care are much like national health systems on a smaller scale. Back in the '70s, the earliest HMOs were even known as "hotbeds of socialist medicine" precisely because, like some governments, they aimed to spread the costs of care over a group of people so sicker people needn't pay more.
The difference, of course, is that, in the U.S., these minisystems are operating as businesses. Today these basic units of our system even the minority that are technically nonprofit are geared to make money in a competitive market. As insured Americans begin to wonder whether our insurance can get us the health care we need, and whether we can even hold on to our insurance, we might also question the wisdom of having our health care providers attempt both to save money and make a profit.