FEW WOULD dispute that our health care system is deeply troubled. Thirty-seven million Americans are uninsured, health care costs continue their exuberant growth, and bureaucracy increasingly intrudes in the examining room. Opinion on solutions is more divided.
We and many colleagues have proposed a sweeping reform of health care financing1 because we are convinced that lesser measures will fail, as they have for the past quarter century. Expanding Medicaid,2 mandating that employers provide health benefits,3 setting up state risk pools, and similar piecemeal attempts to expand access either fuel inflation or install intrusive cost-management bureaucracies—usually both.4 Providing more care to those currently uninsured must raise costs if resources are not diverted from elsewhere in the system. Unless bureaucracy is trimmed, these resources will be siphoned from existing clinical care, a process invariably overseen by yet another layer of bureaucrats.
Medicare epitomizes the problem. It improved access