As we move forward in the 21st century, healthcare issues dominate. We are seeing medical advances that were unheard of in the early 1900s. Organ transplants, for one, have become almost commonplace. Meanwhile, Financing health care has become a political hot potato. Federal and state governments are struggling to provide health care in the face of budget shortfalls and rising costs. With dwindling resources, the question becomes how can those resources be best used to serve the greatest numbers of American people? Who is entitled to what?

One of the greatest opportunities for American public policy to improve the nation’s health is to differentiate between the macroallocation and the microallocation of resources. Those who distribute commonly collected resources, such as tax monies and health premiums, among a group of people macroallocate. Healthcare providers microallocate when their decisions focus on specific patients. We must better think through these two roles.

The individual focus of biomedical ethics is too Narrow to be useful in the macroallocation by payers. Macroallocation involves trade-offs and setting priorities. Distributing commonly collected resources among a group of patients involves very different dynamics than a provider caring for individual patients. Those distributing commonly collected funds do not have the luxury of individualized care. Government must provide multiple services to its citizens, and health insurers must provide service to multiple beneficiaries. Both have comprehensive duties to a wide group of beneficiaries. The scope of the differences between macroallocation and microallocation is considerable.

No nation, state, or health plan in the macroallocation of its funds can assume that its healthcare distributions can meet the cumulative medical need of all its individual members. This is clearer in other nations where the government more directly funds health care.

We must better reconcile individual need with the common resources that fund most of that individual need. Providers theoretically can meet all the medical needs of their patients; states can never meet all the health needs of their citizens. Providers can focus on an individual, but a government must meet many needs of all its citizens in a world of trade-offs and priorities. Providers ration when they fail to provide a medical service to a patient. A state or nation, however, rations both when it denies a needed medical benefit and when it fails to provide universal coverage. All governments ration medicine.

Once we slop avoiding the responsibility of rationing health care, we will recognize the occasional conflict between the goals and ethics of paying for (macroallocating) health care with commonly collected funds and the goals and ethics of delivering (microallocating) health care. To recognize and admit this conflict exists will be politically difficult but socially inevitable. Doing so will require a change in the cultural values of citizens and healthcare providers, but the rewards are gargantuan. America can deliver more health to its citizens for less money once it adopts a broader moral vision of health care.

Medical practice and ethics have been developed without consideration of trade-offs with other public goods, even though taxpayers pay almost half of the healthcare dollar. Government now funds about 45 percent of U.S. health care, and employers fund another 33 percent, bringing the total government and employer share of healthcare funding to almost 80 percent. (a) We lack a means of setting priorities in the macroallocation of health care and the tools for comparing health needs with other needed social goods. We have just begun to analyze the moral framework applicable to the macroallocation of resources.

Public policy has allowed providers to be the definers of the nation’s health and the chief architects of the nation’s healthcare system. We have been assuming, inappropriately, that a nation’s best route to health was to fund medical care one patient at a time, thereby allowing healthcare providers to impose their doctor-patient relationship on taxpayer monies without accountability or oversight. The total need of the group was the sum total of individual need. Public policy has not adequately asked the larger question, “How do you keep a society healthy?” How do we reconcile macroallocation with microallocation? Those who fund health care from collective funds must look beyond the individual to the entire group. When pooling money, we have to ask, “What maximizes the health of those who make up the pool?”

Private Need: Common Resources

The problem of allocating resources reaches beyond public policy in health care. Allowing a physician to focus on the patient and a hospital to focus on who comes through the hospital door lets them ignore what is going on down the street or across town. That is not a criticism, but simply a recognition of reality. Our strengths are often our weaknesses. The single-minded devotion of health providers to their patients makes them inadequate judges of the total system. Lacking the luxury of individual focus, public policy must consider the total moral landscape of public needs. That landscape has shifted in the past 10 years as we have increasingly recognized that we cannot provide everything to everybody. We must recognize that the macroallocation of healthcare resources is not the cumulative total of all individual care.