This is an updated and refreshed version of a post I originally published a few years ago (April 22, 2007).  Given the issues it addresses and the current debate over whether and how to repeal Obamacare, I thought it would be helpful to re-publish it.  My intent is to promote a solution to the current flawed health care payment system that is consistent with human nature and a conservative political philosophy.  Enjoy, or abhor, as your beliefs require:

Who makes your health care choices--you, your doctor, your insurance plan, or your government? Who should make such choices, and who should pay for the delivery of the chosen services? In truth, each of these four entities plays some role in the delivery of health care in America.  "He who pays, chooses," seems to be an empiric truth.  Therefore, who should be paying for the array of wonderful and advanced treatment choices available to us?  This is the critical question that faces Americans and our legislators today, and it seems no one in the Obama Administration is willing to even honestly face up to the true issues.
Our society has come to accept the notion of health care as a "right," and that it should be available for everyone regardless of their ability to pay. This principle collides, however, with the inconvenient truth that someone must pay. As a provider, I wouldn't be in business very long if I did not pay my staff and my office rent and all the other expenses associated with a medical practice.  Even in a Utopian single payer system, one can't magically legislate away cost, no matter how much one denies or ignores.  The tension evident in today's system results from the fact that the users of a given service, poor or not, are largely removed from directly paying for that service. This divergence drives up the costs of care and the demand for services.
In America the linkage between a health care service and its cost is now completely absent for most people, and the result is greater demand at greater cost.  The American people are only dimly aware that at every doctor visit, sitting invisibly in the room, listening, watching, taking notes, sits a third person, someone the patient and the doctor don't even know.  This invisible third person is the payor, and that's the unspoken penalty of de-linking the consumer from the cost of his choice.  The person who pays the bills winds up running the show.  I could give a multitude of examples of the huge and intrusive role of government and insurance company third party payors, but I'll try to illustrate my point with the following:   for every service or good one can think of, the market creates a balance between supply and demand, and cost (or price, more properly) is the expression of that balance. Assuming you're not on food stamps, who pays for your groceries? You do, of course, as you do your phone bill and your car payment and whatever else you buy. Now, again assuming you are part of America's great middle class, how did you choose which car you drive? The answer is that you bought the car you wanted, that fit your needs, and that you could afford. No one expects to pay their employer or the government a monthly premium, and to be given a choice of three different cars to pick from every March. And if my illustration were true, I'll assure you that not only would your car choice be limited, it would be more expensive, as well. Competition is a potent motivator and price cutter, and innovation is its fruit.

I'm a board-certified internal medicine specialist, and I deliver what I believe to be excellent care for my patients. Yet, last year I was only a participant in three of the four available Blue Cross plans in the area. Why was I not part of the fourth? It had nothing to do with my qualifications, but was because I was unwilling to provide my services at the price Blue Cross offered for that particular plan. Meanwhile, I provided exactly the same services for Blue Cross patients in the other three plans, for a fee that I found acceptable. Blue Cross, and employers, you see, are driven by different motivations than patients themselves might be. Why should the employer or the insuror determine whether a patient can see me?  It sounds like care is being rationed, and it is, by the employer who chooses to provide the less expensive plan for his employees.  Why in the world do we accept this ridiculous system?  Even more amazingly, why did the recently deposed Congress choose to make employer-based insurance the foundational basis for its "reform" plan? I submit that the cost, quality, and choice available to patients would be greatly improved if the patients were more directly responsible for the cost of their care.

The so-called "health care reform" pushed and passed by President Obama and congressional Democrats went in exactly the wrong direction.  Instead of true reform, this legislation built upon the worst aspects of the existing health care system by further removing consumers from the consequences of their choices and essentially starving by regulation the promising growth in high-deductible health plans, health savings accounts, and Medicare Advantage plans, each of which put the patient in more control of spending his own health care dollars.  Americans have been given a chance for a do-over of this egregious legislative mistake by virtue of an angry and motivated electorate, and it's my prayer that we're wise enough to take advantage of our second chance.   Let me emphasize here the crucial point of semantics that we're advocating reform of the broken health care payment system.  It is empirically true that health care in America, at the point of the clinical encounter, is generally superb, though such quality won't long survive a fundamentally broken payment system.

Unless we radically change the direction of our current reform efforts, patients will in the future have vast restrictions placed on their choice of doctors, hospitals, treatments, and medicines.  How many dollars won't be spent developing new medicines and treatments, because the money and brain power are diverted to less productive pursuits?  The bureaucracy even now often chooses which medicine to pay for, and which physicians to contract with, and those choices are driven by interests that are often at odds with the patients' best interests. Physicians, for their part, have little incentive to openly publish their fees or compete for patients based on convenience issues such as flexible appointment availability or timely message return. Employers, saddled with the job of picking insurance options for their employees in this inefficient system, are left with a responsibility and cost they'd rather not have, but which has developed, not out of any affirmative policy decision, but because of a World War II era tax loophole for Kaiser shipyard workers.   It's past time to declare that the emperor has no clothes, that the current health care payment system is built on a foundation of sand, and that American exceptionalism demands an exceptional health care system!

One of the least appreciated but most terrible results of our current "accidental" system is the erosion of the doctor-patient relationship.  In its ideal form this is one of the most precious and protected of human relationships, one that for the patient lends itself to a feeling of trust, security, and hope, and for the physician yields an incredible sense of duty, responsibility, and obligation to his patient.  I've had the privilege to have this relationship with some of my patients, but it is no longer the norm.  Do you as patients think you've lost anything with the loss of this type of relationship?  Do you even recognize that it's gone?  Do you get a glimpse of the magnitude of the lost job satisfaction of physicians whose practices have bridged this transition?
The surest path to a successful solution will be one in which the individual patient maintains maximal control over his own health care decisions, and that recognizes that it is the payor who has the control. I've chosen to be a physician for the freedom and blessings that are its fruit, both for me and for my patients.  On a broader scale, I hope Americans will continue to have a rich array of health care options in future years. It's not a given that we will.