The escalation of health care costs in the United States has become a problem now that business and taxpayers are paying larger shares of these costs. Many believe that the only way to cope with rising costs is to institute explicit rationing of access to health care services. Proposals to ration based upon age, "sin" exclusions, physician gatekeeper incentives, patient ability to pay, and community values all have shortcomings. An alternative approach to controlling costs that emphasizes efficiency by cutting administrative and malpractice overhead costs and universally providing those medical services that have proven patient benefit is proposed. Physicians must take a more active role in the debate to ensure that patient needs are met and that expenditures are directed toward effective therapies.