Before I start, you need to know where I stand. I think the ideal plan is high deductible insurance, all medical care tax free for individuals as it is for corporations. This will preserve medical freedom and medical privacy. At the same time, I believe that we as a community should provide care to those cannot care for themselves, with strings attached as they must be to keep costs reasonable.

Why do I think this?

Point 1

Over the years of dealing with people who are ill, I've noted that people are rational about paying for their own health care.

"I need an Xray? I'm gonna be paying? How much does it cost, doc? You sure I can't I just keep an eye on that ankle and xray only if needed?"

or I might hear "You know, doc, I agree my ankle is probably ok, but there is a chance it might be broken, and my insurance pays anyway, can't we just get an xray so I'll know right away it is ok and I won't have to worry about it?"

Once a lady came in and said "I just heard that Medicare pays for six physical therapy treatments a year, and I'd like to get them."  I pointed out that Medicare intended this benefit only for those who had a requirement for it.  "Oh, I didn't know.  But, yes, now that you mention it, I've got some pain here and here."

Conclusion 1:

If something is free, or common property, many people, not all, will use or abuse it. When something has a cost, people conserve it.

Point 2

Some years ago, one of my patients needed a hernia repair. His local doctor estimated a cost of about $6000. My patient looked around and found Dr Kugel in Olympia who specializes in hernia repair and would do it for $2500. Dr Kugel also got my patient back to work faster than the local surgeon estimated. Dr Kugel now teaches his innovative techniques to other surgeons.  (Addendum 2006: Dr Kugel has retired.)

In our own office, because we do not participate in any insurance plans including Medicare, we need to work to attract patients. So, we publish our fees on our website. We can do this because we have the same fee for everyone, and not fifteen fee schedules for fifteen different insurance plans.

We have home remedies for common problems that we make available to our patients at no charge. We do this because we need to give our patients a reason to select us instead of the doctors up the hill.

For a low, set price, we will evaluate and treat a sore throat, including lab work and medication. For a low, set price, we'll do the same for a woman's urinary tract infection. We can do this because we don't have to guess whether we are going to be paid or not. Insurance companies have no code for these services. OK, we can live with that.

We see many patients with problems other physicians haven't solved. We spend as much time as needed, and do whatever tests are needed. We can do this because I don't have to convince a non-physician at a computer screen in Omaha that the time or the tests are necessary. The patient decides.

Conclusion 2:

Competition not only reduces prices but encourages creativity and improvement in technique.

Point 3

Medical care is not a commodity like pork bellies. Sometimes you have an individual who is interested in their own health and is willing to make changes to achieve good health. Sometimes you have someone with no interest in making changes unless they are forced to.

Whether you are a physician, a drug-treatment center, or an agency paying for health care, you need to realize that confusion in identifying these two groups of people is extremely costly.  Your approach needs to be tailored to the individual..

Conclusion 3

I think you can figure this one out yourselves. Just one question, though. Why make a bogeyman out of a two-tier system? In my view, that's a multifaceted system designed to best meet the needs of those served.

Point 4

We face problems similar to medicine's problems in our school systems. Costs up, satisfaction down. Those who oppose privatization often say that everyone must pay taxes for public schools, with no tax break or vouchers for private schools, because otherwise the general public will lose its interest in paying taxes for schooling for the disadvantaged.

Now, the argument for publicly funded medicine is this. If we can put everyone's money in one large pot, then by some magical bureaucratic legerdemain, everyone will get better service.

And if the bureaucrats have trouble, if paralysis hits the health care system as it has hit the schools, at least the rich will have to support the system because they are in the same boat with the poor.

Conclusion 4

The impasse in the schools and the impasse with medical payment schemes are similar. In each case we have those who believe that somehow we can govern better, reach a societal consensus better, accommodate every possible need, and somehow come up with one solution that works for everybody.

And we have those who believe we will do better to trust the intelligence of individuals to make rational choices.

In summary:

The Clintons couldn't pass national health care because they believed the polls 'health care should be free.' They didn't understand a stronger conviction "if I can get better health care on my own than the government will provide, I want that freedom."

And that is what I, and many people of like conviction, are working for.