The UK uses a centralized body (NICE) to make explicit cost-benefit decisions about what care to cover; the US achieves similar rationing through opaque administrative sludge.
Where this was said
At 21:00 · chapter starts 18:20
The conversation turns to the deeper architecture of healthcare sludge, and Handel makes his most explosive claim: in all healthcare systems worldwide, care must be rationed because society refuses to let price alone determine who gets treatment. The UK does this via NICE — a body that makes explicit, published cost-benefit decisions and via waiting times. Canada and other countries have similarly organized mechanisms. The US, having a privatized system, has pushed this rationing responsibility onto private insurers. Each insurer constructs its own opaque basket of rationing policies — prior authorizations, provider network mazes, confusing deductible structures — none of which consumers understand when they pick their plan. You only discover the rules after you need care. This, Handel confirms plainly when Dubner asks: healthcare is rationed by sludge. And no, it is not unintentional. Coming back from a break, Dubner notes that UK Prime Minister Keir Starmer announced plans to abolish NHS England to cut bureaucracy — calling it 'stodge,' sludge by another name.
US health insurers use administrative complexity — prior authorizations, impossible provider searches, endless paperwork — not out of incompetence but as a rationing tool. Ben Handel confirms: this is not unintentional. Every healthcare system rations; America just uses sludge instead of a waiting list or a published rule.
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