John was 50 years old. He had hypertension, diabetes, and a third and equally insidious condition—no health insurance. Although John had found sporadic medical care in emergency departments and “sliding-scale” clinics over the years, decades of spotty management had irreversibly damaged his kidneys and placed him on the list for hemodialysis. The good news is that dialysis—the only procedure categorically paid for by Medicare—allowed him, finally, to qualify for health insurance.

But isn’t there something perverse about a health-care financing system so dysfunctional that it’s necessary to kill a person’s nephrons before we’re allowed to nurture them?

We spend 40% more per capita on health care than any other country on the planet, yet the World Health Organization ranks the United States 37th in health performance. That’s pretty dismal for the richest country in the world.

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Politicians receive millions in campaign contributions and, not surprisingly, continue to pour money into the medical-industrial complex. Wasting tax dollars this way threatens our fiscal integrity. Placing more bandages on a collapsing system seems crazy.

With that in mind, let’s stop and investigate three simple questions:

• When it comes to health care, what goods and services do we want to deliver and to whom?
• What’s the most equitable and economical way to fund what we want to deliver?
• How do we get started down a new path?

Instead of saying, “We have this much money. Figure out what we can deliver for that amount,” ask which services should be delivered and who should deliver them, to whom, and where.

This discussion would force us to confront the simple reality that virtually everyone wants high-quality, affordable health care for all. And that we would rather prevent disease than spend huge sums on treatments and disability payments.

So, if we want good health care for all, what’s the best way to pay for it? I suggest we follow the rule “Everyone contributes, everyone benefits.” To that end, let’s replace medical-insurance premiums with progressive taxes—all citizens pay a percentage of their income into a national health-care fund. For most of us, this would be much less that what we’re currently spending.

In order to ensure quality and freedom of choice, we would keep the delivery system in private hands. However, unlike what happens under our current prescriptive system, we would place a great deal of emphasis on prevention and team approaches to care.

With a national health-insurance system, a person could select any health-care provider or hospital she wants. We would then pay our providers to do everything possible to prevent and, if necessary, manage diabetes and hypertension so we could reduce the number of patients we have to dialyze. We’d do the same, of course, for other conditions.

Sick of the system? Get involved now. The health-care plan of the winning 2008 presidential candidate will shape health-care financing for the next decade. Find out what the candidates are really saying about this important issue. Then be a health-care voter and vote for the candidate with the best plan. Do it for your profession. Do it for your patients.

Do it for yourself. For additional information, visit or

Walter Tsou, MD, MPH, is a public-health consultant and former Health Commissioner of Philadelphia.