PORTLAND – The problem of unaffordable health care has gotten so bad that the middle class is joining the poor in being priced out of coverage, a national expert said Tuesday.

Relying on reducing waste, abuse and fraud, and on reforming malpractice litigation won’t be enough to bring down costs and cure the sick system, said Dr. Paul Ginsburg, who heads the Center for Health System Change.

The country is going to have to ration care, and people will have to “give up” something, because the system is unsustainable, Ginsburg predicted. “The notion that all should get all the care they might have now is leading to some having to go without,” he said.

Ginsburg, who is considered one of the more influential people nationally in health care, spoke to health and business leaders Tuesday at The Health Care Cost Coverage Conundrum, a conference sponsored by Anthem Blue Cross/Blue Shield.

More people going without coverage is a problem because it translates to poorer health and financial problems. “Medical debt is one of the leading causes of bankruptcy in this country,” Ginsburg said. In government, rising health costs are crowding out other priorities, especially at the state levels, and will lead to higher taxes, he said.

But with the exception of Maine, most leaders are not talking about the problem, “and for good reason,” he said. “Serious cost containment means that some people are going to get less care, and providers will get less revenue. This is something leaders don’t like to talk about unless they absolutely have to.”

Cost containment and rationing will eventually happen, not because people are going to suddenly decide that health care taking up 17 percent of the Gross Domestic Product is too much, but because more will be stressed by costs.

Successfully figuring out how to cut costs won’t be easy, he cautioned. It will require leadership and close attention to what works with American values.

“We can’t duplicate Canada” because citizens here would not accept government having such a heavy role in health care, Ginsburg said. “Let’s be realistic and think in terms of what might be feasible rather than what might work well in some other place with a very different culture.”

Market approaches need to be supported where they will work, since the country “is a market economy.” But there are some situations where there is little potential for market competition to do the job. “In those areas we have to think about public utility approaches,” he said.

When asked what he expects from Washington in the next four years, Ginsburg wasn’t hopeful. Given the budget deficit, Ginsburg said he doesn’t expect any large expansion of health coverage. The Bush administration is enthusiastic about medical savings accounts, but some high-income people consider those accounts “tax shelters,” he said.

After listening to panel discussions about Maine’s health care situation, Ginsburg concluded that Maine’s unaffordability problem is more serious than other states. Gov. John Baldacci’s attempt to lower costs through Dirigo is impressive, he said, and a reflection of the difficulty middle-class Mainers are having affording care.

When asked about Dirigo, Ginsburg said he was reluctant to give Maine advice, but did offer advice for stakeholders who will continue to debate about how to build a better health care system.

“Stakeholders do have to look after their interests, but they ought to think about what’s their second choice,” Ginsburg said. “The message is compromise.”