A health-care judgment day is coming in America, and the nation must start discussing how to ration care fairly and still provide basic health care for all, former Colorado Gov. Richard Lamm told a health-care conference here Monday.

"Nobody can say 'no' to anything in our health-care system," he told about 200 people at the Montana Healthcare Forum in Helena. "But if you want to get to the future, we're going to have to learn how to say 'no.' "

It's been 23 years since Lamm made his famous "duty to die" statement, when he said extraordinary amounts of money shouldn't be spent on artificial hearts and other medical miracles to keep elderly, unhealthy people alive for a few more months or years.

On Monday, his message sounded much the same, but he said it's become even more urgent now, with millions of baby-boomers approaching retirement and fewer young people to help pay for their health care.

The tax-supported systems of Medicare and Medicaid, which often pays for nursing-home care for the elderly poor, cannot be sustained without major changes in our overall system, he said.

"We're going to have to run a nation of 50 Floridas," Lamm said, referring to its aging population. "We've never had to run a society like this before. Our medical miracles have moved beyond our ability to pay."

Lamm, looking fit and trim at age 72, didn't offer a neatly wrapped solution. But he said the fix will have to include a frank discussion about where to spend limited resources on health care.

A nonprofit system coordinated by the government is the preferred way to go, he added, saying the "free market" doesn't work that well in health care and health insurance.

In a brief interview after his speech, Lamm said he preferred Germany's model of universal health care, in which citizens pay into one of several hundred state-regulated insurance pools.

Lamm was one of several speakers at the first day of the two-day forum, which is co-sponsored by Montana Blue Cross/Blue Shield and Carroll College.

The forum, attended mostly by health insurers and health-care administrators, providers and policymakers, is offering a broad look at Montana's and the nation's health-care system and possible reforms.

Lamm, co-director of the Institute for Public Policy at the University of Denver, said it's a "national shame" that the United States has 47 million people without health insurance, and that while we have excellent physicians, hospitals and technology, we don't have the best health-care system.

Care is rationed in the United States by denying care to those without insurance, and we deny care more than any other industrialized nation, he said.

Nonetheless, Lamm said it's "inevitable" to have a two-tiered system, in which people with money are able to buy better care than those with little or no money. The trick is to broaden that lower tier so those with less money have access to some basic level of good care, he said.

The free market is not a good way to ration care, Lamm said, because the purchasers are often sick and frail, and the health insurance market tries to push out those who are in poor health.

"I'm very suspicious of these mandates to purchase (health) insurance," he said of reform proposals being floated by some, noting that people with "pre-existing conditions" would still face very expensive prices when shopping for insurance.

Still, switching to a system funded more by the government will be very difficult, Lamm said, noting that American employers currently pay $800 billion of health-care costs.

"For those of you who want a Canadian-style (taxpayer-funded) system, we must transfer that (amount) to taxes," he said. "That's a major roadblock.

"It would be worth it, but I can say that now, because I'm not running for office."

A more coordinated system is needed, however, to decide how best to spend medical resources and not waste money on care of minimal value, Lamm said.

"My human body is a financial black hole into which you can pour endless resources," he said. "It has become an economic crisis that is crowding out everything we have to do as a society."