The seemingly inexorable rise in the cost of heath care isn't just an issue in Bermuda, but around the world.

There are a number of reasons why health care costs consistently outpace the overall rate of inflation.

One is that people are living longer, meaning the health system is handling more patients more often. As the baby boom generation moves into retirement, this will increase because as demand for services increases, so do prices.

Exacerbating the problem is the fact that increased access to increasingly sophisticated means of diagnosis and treatment leads to increased use. MRIs, CT-Scans and all the modern paraphernalia of medicine are fantastic diagnostic and treatment tools, but they cost money – and when they are available they get used more, sometimes unnecessarily.

The medical research and the (thankfully) vast amount of testing required before a new drug goes on the market costs a fortune, and the cost of research and testing that does not work out must be recouped as well. The dirty little secret, though, is that vast amounts are also spent on marketing drugs, and that cost goes straight to the consumer.

In general, Bermuda residents expect a high standard of medical care and when they don't or can't get it here, they get it from the best and most expensive hospitals in the world. That is not necessarily wrong, but it also drives up costs.

Bermuda has its own inbuilt costs as well. Since labour and services cost more in Bermuda than almost anywhere else, these costs are added to the bill.

Two other Bermuda exceptions that have driven costs up recently are the decision to add one percent to the hospital benefit in order to fund the the new hospital. And how patients are charged for hospital services has also changed. In overly simplified terms, the hospital used to charge a kind of all-inclusive charge where the cost to the patient was largely dependent on length of stay. This has now been changed to an itemised bill, where patients are charged for the services they received. This is fairer, but it also means that the cost to the patient has risen while the cost to Government has dropped.

Health Minister Walter Roban correctly said this was simply a matter of shifting costs rather then increasing them. But because taxes have not fallen while charges to insurers and therefore patients have risen, the net result is a higher price to the consumer.

Now Mr. Roban is promising that Bermuda is on "the verge of a revolution" in health care, although he is being deliberately vague about what that means.

He did indicate there might be a move away from branded drugs to generic drugs, which should result in a lower cost to the consumer. He has also said the hospital benefit is being looked at.

But after that, most of the choices in health care come down to three options, none of them easy or palatable.

One is to restrict the services available to patients, or to dole them out on the basis of need.

Another is to restrict the kinds of hospitals Bermudians can go to abroad, so patients don't end up at the most expensive ones. All of these options take away choice even as they reduce cost.

Government officials have also spoken of the possibility of opening up health insurance to foreign providers who, in theory, have the economies of scale to lower costs to patients. But they are also notoriously callous when it comes to patient care.

Bermuda's system of health care and health insurance has served it well for close to half a century, but is now showing signs of unravelling. As all have said, it should be possible to deliver good health care at a reasonable cost; there will be hard choices to be made, but first it needs to be discussed.