OPINION/By RICHARD SEARLES, Journal Contributor
How medical rationing by inconvenience quietly limits who gets care
When most people think about medical rationing, they imagine an insurance company denying a claim or refusing to cover a treatment. Those decisions are usually clear, frustrating and easy to recognize.
But a quieter form of rationing is increasingly shaping how patients experience health care — one that rarely involves an outright denial.
It is known as medical rationing by inconvenience, and it works by making access to care so time-consuming, confusing or exhausting that many people stop trying.
Barriers instead of bans
Rationing by inconvenience does not prohibit care on paper. Instead, it relies on administrative obstacles: complex forms, repeated approvals, strict deadlines, long waits and difficult appeals.
The treatment may technically be covered. The problem is getting to it.
Appealing a denied insurance claim is a common example. Patients are often told they have the right to appeal, but the process can require extensive paperwork, medical records, letters from physicians and multiple rounds of review. The process can stretch on for months.
Some patients eventually win. Many others give up long before then.
Prior authorization requirements operate in much the same way. Doctors must seek approval before prescribing certain medications or ordering tests, often submitting the same information repeatedly. Delays are common, and treatment may stall while paperwork circulates.
Delays that discourage care
Long waiting lists also serve as a form of rationing. Extended delays for specialists, imaging, procedures or surgeries can discourage patients from continuing care. Some conditions worsen while patients wait. Others go untreated when people decide the effort is not worth it.
Health care workers feel the impact as well. Physicians and nurses report spending increasing amounts of time navigating insurance requirements rather than treating patients. Faced with heavy administrative burdens, some providers avoid certain treatments altogether — not because they lack medical value, but because the process to obtain approval is too onerous.
Not everyone is affected equally
Rationing by inconvenience does not fall evenly across the population.
Patients with flexible schedules, higher incomes, strong education or professional advocates are more likely to push through bureaucratic barriers. Those with fewer resources — including hourly workers, older adults, people with disabilities and patients managing chronic illness — are more likely to abandon care.
The result is a system that quietly reinforces existing health disparities, even while claiming to offer equal access.
Hidden rationing in plain sight
Unlike explicit coverage limits or drug formularies, rationing by inconvenience is largely invisible. No policy document says care should be discouraged. No letter states that patients are expected to give up.
Yet the outcome often mirrors direct rationing.
Because access technically exists, insurers and health systems can claim coverage while controlling costs through delay and complexity. Health policy experts sometimes describe this approach as “covert rationing” — limiting care without openly acknowledging it.
Ethical questions remain
Some ethicists argue that indirect rationing can be a practical way to manage limited resources, especially in systems under financial strain. Compared with outright denials, inconvenience-based limits may appear less harsh.
Critics counter that the practice is ethically troubling because it shifts decision-making away from transparent rules and toward a patient’s ability to navigate bureaucracy. In that model, persistence — not medical need — often determines who receives care.
Why it matters
For patients, rationing by inconvenience can mean delayed diagnoses, missed treatments and poorer health outcomes.
For the health care system, it raises a fundamental question: Should access to medical care depend on how much time, stamina and paperwork a person can endure?
As health care costs continue to rise, how care is rationed — openly and transparently, or quietly through inconvenience — will remain central to debates over access, fairness and trust.
“Richard Searles is a regular contributor to The Parish Journals of Louisiana. The views expressed are the writer’s own.”