Health Economics, Policy and Law

Special Section

The political economy of rationing health care in England and the US: the ‘accidental logics’ of political settlements

Gwyn Bevana1 c1 and Lawrence D. Browna2

a1 Department of Management, London School of Economics, UK

a2 Deparment of Health Policy and Management, Mailman School of Public Health, Columbia University, USA


This article considers how the ‘accidental logics’ of political settlements for the English National Health Service (NHS) and the Medicare and Medicaid programmes in the United States have resulted in different institutional arrangements and different implicit social contracts for rationing, which we define to be the denial of health care that is beneficial but is deemed to be too costly. This article argues that rationing is designed into the English NHS and designed out of US Medicare; and compares rationing for the elderly in the United States and in England for acute care, care at the end of life, and chronic care.

(Received September 01 2013)

(Revised February 28 2014)

(Accepted March 05 2014)

(Online publication April 23 2014)


c1 Corresponding to: Gwyn Bevan, Department of Management, London School of Economics and Political Science, Houghton Street, WC2A 2AE London. Email: