Good plan, major flaw

...Everybody cannot have everything, and limits must be agreed to consensually...

...The plan continues the trend of emphasizing the importance of primary care and primary-care physicians...

...While chafing the wrists of some physicians who genuflect toward the altar of autonomy, the plan's emphasis on integrated health-care networks (essentially today's HMOs) is also a movement in the right direction...

...Without real nonmarket-based limits to the supply of healthcare resources, cost containment is wishful thinking...

...Now, a year later, while Benjamin is wreaking havoc in our house, nothing in President Bill Clinton's plan to reform healthcare delivery and financing in the U.S., nor any of the numerous counterproposals, addresses the root causes of rising costs (and the resulting inequity) in the U.S...

...In practice, however, single-payer plans face entrenched opposition from powerful interests and a public wary of government bureaucracy and any hint of limits to treatment options...

...insurance companies will try to dismantle the proposed health alliances to strengthen their future role...

...The process of providing effective, efficient care is too complex for all involved (hospitals, physicians, and financiers) not to have a mutual stake in its success...

...Clinton have succeeded in their most important challenges—making some sort of reform inevitable, and making universal access a sine qua non of their plan...

...On the financing side, detractors will question whether mandated employer provision of health ben8 efits is economically wise or necessary...

...While administration of these alliances may be problematic, their potential for ensuring equal access, including integration of Medicaid and Medicare populations into a general pool for health-care financing and delivery (rather than isolation and stigmatization), is significant...

...The chief battles figure to be fought around benefit definitions and financing...

...Some complexity is inevitable, given the scale of the endeavor...

...Beyond the concepts of "health-care security" and "preservation of choice," however, the administration's message to the public has been muddled...

...Yet giving 37 million uninsured people health-care insurance and improving the coverage of millions more guarantees additional expenses...

...The chief means to these ends are equally laudable...

...The conceptually clearest alternative to "managed competition"—the administration's proposal to create a market for healthcare services and insurance by defining a common product, developing saftey-net and financial-assistance packages, and then letting the market make production more efficient—is the single-payer system, in which the government would take over the insurance and financing function completely...

...The plan also manages to gore one of the more sacred (and costly) cows in the health-care pasture by having everyone contribute directly to the financing of their health-care premiums and service co-payments on a means-tested basis...

...Physicians will advocate for less intervention by the government or anything else in their work...

...Health Alliances" are giant purchasing cooperatives through which all but the largest employers would purchase their health insurance, providing economies of scale and ensuring a uniform regional health insurance market...

...The biggest difference between the Canadian and U.S...

...Cost containment in 7 REPORT ON HEALTH-CARE REFORM GOOD PLAN, MAJOR FLAW MARKET FORCES CANT CONTAIN COSTS the plan occurs primarily by informed individual customers (newly vitalized with their higher financial participation) selecting efficient health plans...

...the forces that added about two thousand dollars to the cost of Benjamin's delivery, with no difference in outcome...

...The core of the debate over health-care reform addresses the merits of governmental activism...

...Supporters for such a plan point north to Canada, whose single-payer plan boasts equal or better patient health status, universal access, and high patient satisfaction with low per capita health-care expenses...

...Managed competition, they maintain, is a ruse concocted by large insurance companies who will expand their control and limit patient choices...

...Finally, a market-based reform will not address the inequities in the allocation of expensive last-resort technologies...

...Then after a birth with no major complications, he and his mother stayed two extra days in the hospital while pediatricians verified that his brief fever was due only to temporary dehydration...

...Freedom of physician choice, another would-be pillar of health-care services in the U.S., would be limited slightly (you would select the network which has your doctor), but the plan allows all citizens to choose a (presumably higher priced) package with no limits on provider choice...

...The absence of these elements from most employer-sponsored insurance programs and the fact that health benefits are currently nontaxable have contributed to over-utilization of health-care resources in the past...

...In another example, lax state approval efforts have resulted in twenty-two Magnetic Resonance Imaging Units in western New York state alone, more than the entire country of Canada...

...The prospects for the passage of reform legislation in 1994 are real, but the prospects for Clinton's reform plan, unamended, are nil...

...Revenue and expense proposals and estimates will come under close scrutiny and continuous revision, and advocates of a single-payer proposal will lobby to make their option available to any state that favors such a system...

...When resources become available they will become the "standard of care" (who are we say no to an ultrasound to make sure our baby is all right...

...Research has shown the number of surgical procedures per capita in a region to be the function primarily of the number of surgeons available, prompting calls for "professional birth control...

...The president and Mrs...

...President Clinton has said he is ready to compromise on major portions so long as universal coverage is maintained and numerous congressional counterproposals appear ready to take him at his word...

...Finally, the Clinton plan fails one of the principles the president himself set out in his address to Congress last September— simplicity...

...The financing of the plan remains particularly arcane, with numerous partially developed sources of revenues and poorly articulated consequences for citizens...

...Finally, one of the more poorly understood attributes of the proposed plans is also one of its strongest...

...Currently six of every seven medical residents selects specialty care rather than primary care...

...Members of Congress have complained they should not be asked to vote for something they could not explain to their constituents...

...Podiatrists, chiropractors, mental-health advocates, pharmaceutical manufacturers, and others will all lobby to get their piece of the pie as well...

...Like Churchill's democracy, government activism in health-care delivery and financing may be acceptable only in comparison to all the known alternatives...

...whether or not they change patient outcomes...

...In the case of our son, twenty years ago, prior to the advent of ultrasonic examination, labor for post-due-date babies was either induced or waited out, sometimes with tragic consequences...

...In the face of this complexity, discerning questions need to be asked...

...Catholic Bishops' 1986 pastoral letter on the economy, Economic Justice for All, asked "what does a healthcare delivery and financing system do to people and for people...

...There is little in the plan to promote less technologically intensive deaths...

...Now, in theory, health plans would be motivated to separate unnecessary from necessary testing—a rather optimistic assessment of their capacities...

...To be sure, there is plenty to applaud in the plan...

...That said, its basic drawback lies in its faith in another American tenet: the power of the market to cut costs and allocate resources efficiently...

...There is no mechanism to insure the equity of their use, or evaluate their relative merits...

...Cost constraints are minimal, they say, noting that rates of increase in Canadian health-care expenses rival those in the United States...

...More than many other human rights, equal distribution of health-care resources is a moral imperative for a society...

...Currently, their dissemination occurs in a haphazard manner, driven by academic medical centers and zealous patient advocates anxious to combat a tragic untimely death, such as the pediatric cancer victim...

...Single-payer proposals, which have attracted a strong minority of supporters in Congress, represent in theory the best prospect for diminishing the strength of the pharmaceutical, diagnostic technology, and high-tech medical intervention industries: the unholy alliance responsible for inducing and feeding our society' s demand for the best and the most advanced treatment, in the name of medical progress and individual choice...

...Its proposed benefit package focuses on immunizations, physicals, and preventive care...

...Much as we have come to fear the ability of our government to do anything well but incur debt, the imperative of health-care reform will require a significant governmental role...

...and lobbyists for the elderly will attempt to preserve as much of the preferential cost and benefit treatment provided through Medicare as they can...

...CHRISTOPHER F. KOLLER Christopher F. Koller lives in Buffalo, New York, where he works for a health-maintenance organization...

...health systems, some have observed, is the patient...

...Yet our society cannot financially or morally rely on the invisible hand to allocate limited healthcare resources among numerous treatments and patients...

...The story is the same for specialty care...

...The most rancorous benefit is sure to be abortion coverage, which the Clintons finesse with an "include but discourage" position...

...First, by hanging around eighteen days past his due date, Benjamin incurred extra tests, as obstetricians assessed the continued ability of his mother's womb to support this latecomer...

...These are impressive sea changes in public attitude...

...Similarly, mandated community rating, in which an insurance company charges one price for its basic package to all purchasers rather than varying it by the individual group's experience and unfairly penalizing costly individuals, is a significant step toward a more equitable system...

...The administration is trying to dodge a big bullet—the tax word...

...In short, the plan is Clintonesque: determinedly idealistic yet politically pragmatic...

...A solely market-based paradigm ignores that demand for health-care resources—specialty care, pharmaceuticals, or diagnostic testing—expands to utilize the supply available...

...Between the extremes of a fear-induced "do everything at all costs" command from the patient's family and the right-to-die movement lies a death which respects mortality and its power over us—what Daniel Callahan refers to as a "good death...

...No reform proposal which fails to enhance the dignity of the human individual by ensuring the universal availability of health care for future generations merits consideration...

...The U.S...

...Estimates of cost savings are inspired guesses, and the proposed patchwork financing strains the synapses and the credulity of the public...

...The Clinton plan, while attempting to address the issue, adequately adjusts the graduating or practicing mix of M.D.'s closer to the 50/50 ratio usually considered optimal...

...health system...

...Expansion of the Medicare Patient Self-Determination Act, and simplification of the often abstruse or legalistic language of living wills and other advanced directives (the state of New York's "Health Care Proxy" is an admirable exception to this) would be welcome additions...

...Finally, three powerful advocacy groups will want to get their licks in...

...Too often, expensive and fruitless end-of-life interventions result from poor preparation and communication among the patient's family and physicians, and a culture which fails to acknowledge limits...

...Detractors, however, raise the specter of socialized medicine and an interventionist government, greater constraints on physician practice, and queues for complex medical services...