One of the most vexed issues experienced-not just in Australia, but internationally-is that of rising health care costs and the predicted blowout in health care spending for early next century. This chapter examines the factors that are driving up health care costs. It presents a discussion of how health rationing decisions have been made in other countries—in Britain (under the Conservatives and New Labour), the USA, New Zealand and Australia, and the various schemes devised to meet the challenge of capping expenditure while maintaining choice, accessibility, affordability, universality and quality of services. Reforms include GP budget-holding, consumer charters and citizen juries in Britain; managed care and the Oregon Health Plan in the USA; market-based reforms, including increased consumer co-payments and tighter eligibility criteria, in New Zealand; and the Australian Coordinated Care Trials. The chapter raises questions as to who should shape the future of health care provision and how allocative and cost decisions should be made.