Discretionary power is commonly defended by denial of its existence, the allegation of inevitability. Objective external conditions and forces are claimed to dictate policy decisions with tangible distributional effects. In health policy, such forces include the aging of the population, the extension of technology, and the demands of ethical standards. Taken together, these forces create relentless upward pressure on costs, to levels which society "cannot afford," necessitating sacrifice of the interests of the "less eligible." Yet quantitative analysis of these forces does not sustain the argument; in each case the source of cost escalation is not external pressure but the way in which the health care system itself reacts. Less costly and equally effective options are demonstrably available, but would threaten provider interests and broader ideologies. A spurious cloak of inevitability serves to promote and justify political choices.; KIE: Health policy analysts generally attribute the recent rise in health care costs to the inexorable pressures of an aging population, new biomedical technologies, and an ethical imperative to provide those health services which providers consider appropriate. These forces are seen as driving costs to a level that society cannot afford, thus necessitating cuts in services to groups such as the elderly and economically disadvantaged. Basing his analysis primarily on Canada's success in containing the growth of its acute care system, Evans argues that such external pressures are not the true source of cost escalation; rather, the problem is rooted in the nature of the U.S. health care delivery system. He contends that the "medical-industrial complex" ought to be brought under control through the judicious use of incentives for competition.