A government has a duty to the people it governs. A nation that ignores the fundamental healthcare needs of its residents is foolish and ultimately doomed. Eradication of infectious diseases, prevention of diseases and traumatic injuries, and preparedness for natural and terrorist disasters are essential components of public health policy.

There is nonpartisan momentum in the media today for universal financing of healthcare. Is this health reform momentum proceeding in a purposeful fashion toward a defined program or is it just a lot of talk buzzing about in heat-accelerated but random Brownian motion?

Do we really have an overwhelming consensus for universal coverage for all, or for some, or not at all? If we truly have consensus, then we must begin with an end in mind. What is our goal, our end game? Specifically, what do we consider acceptable as a minimum essential benefit? Exactly what do we require in a basic healthcare package and what are we willing to exclude? What is the essence of essential healthcare delivery?

We spend billions upon billions on various government programs, billions upon billions on foreign aid, and billions upon billions on foreign wars. Americans spent $16.7 billion to celebrate Valentine's Day this year. It is inconceivable to me that our noble government won't allocate a few billion more to form a basic healthcare coverage program that includes the aforementioned essential prerequisites as well as a medically necessary standard program for the poor, the disabled, those whose medical conditions put them near the end of life, and those in the precious early years of life.

A healthy and productive population reinforces a healthy and productive government. Yet AADD--Aged American Disability and Depression--continues to grow much like a 21st century plague, and there is not sufficient federal funding or adequate federal reserves to care for that increasing problem properly.

However, I do not advocate that our government pay for total healthcare for each and every resident. Such a system would quickly bankrupt the government and insult a person's pride in personal responsibility. Government-financed healthcare would not only bankrupt the country, but would also present an insurance hazard to personal responsibility resulting in an abandonment of preventive care. The very nature of such a system would eventually squeeze, scare and shortchange patients.

As Americans, we have a right to be able to act, to do, to produce. Our constitution affords every American the right of opportunity; no rights of habit or indulgence are stipulated. The purpose of healthcare coverage for children and mass education is to ensure a healthy and productive population in the future.

Patients have the right to act by way of voting. Through that productive process, patients can demand that their democratically elected representatives legislate a healthcare financing system into the law of the land. Those 18 years and older can deliberate and elect officials who theoretically deliver the preferred type of government and regulation. In addition, California enjoys a separate initiative process in which the people can act freely, directly enacting law from propositions apart from their legislators.

Before legislative action occurs, the people--our patients--should have a chance to voice their will through our democratic voting process. In the educational process of voting, our patients will come to a better understanding of the healthcare value that our government will fund.

If the people do not want universal healthcare coverage, or if the people are not wiling to pay for basic coverage, then that serious conundrum needs to be publicly debated and solved first--before our legislators bring about an undesired solution or a solution with unanticipated harmful consequences.

In any healthcare delivery system, patient care must focus on individual patient needs and be administered by practicing physicians through the sacrosanct doctor-patient relationship. Any delivery system should seek to facilitate and enhance that doctor-patient relationship. Government financing must be driven by medical necessity and adequately address individualized patient-centric care. Further financing for additional layers of healthcare service should be at the sole discretion of the individual patient.

Because our present system is inadequately funded, tax credits and tax deductions to inspire incentives might help, but incentives won't be enough to adequately pay for care in a universally covered system. We must eliminate the bureaucratic processing entanglements, red tape and layers of nonproductive administrative interference that shrink the dollars that actually go to hands-on patient care. We must eliminate the undue cost attributable to the practice of defensive medicine with tort reform. We must eliminate the constraints of restricted access to tests and procedures along with delays, down coding and denials, all done to enhance profits for stock market investors.
 
A sustainable and growing funding source for adequate remuneration is a sine qua non prerequisite for an individualized governmental program. A sales tax increase or an income tax increase will be ultimately necessary to support naturally increasing costs in basic universal coverage.

Mandates are worse than simply useless; mandates are counterproductive and increase costs. Coercion is an infringement of personal liberty. All mandates should be allowed to expire after a fixed period of time. It must also be clearly understood that basic healthcare coverage will not spur patients' desires to optimize their total health. Since the payer tends to make the rules, the best payer is the individual patient.

Health insurance is just one of many ways to finance healthcare delivery. Financing to optimize a patient's functional capacity can also come from a patient's out-of-pocket money, prefunded health savings and loans, government programs, tax-free corporate grants, business employment, philanthropy, and individual or collective physician charity.

In order to reduce cost, health insurance must be sold in a transparent and competitive marketplace. An ideal insurance would feature comprehensive benefits and be portable without restrictions for pre-existing medical conditions or changing medical conditions, with dedicated dollars for noncontracted and point-of-service healthcare delivery. Ideally, the contracting and reimbursement structure would be directly with the patient. In a free market, all types and all levels of insurance would be offered, and individuals would have the opportunity to choose the price and benefit package that best suits their needs.

The pharmaceutical industry is our friend, an exceedingly rich friend, but nonetheless a true friend. Although they are expensive, drug treatments have significantly increased the American lifespan. Many of us cannot live from day to day without pharmaceutical support. However, competition among the Big Pharma companies has been limited because of excessive regulation and mandates by the FDA, which is more concerned about political influences and fear of lawsuits than the simple reporting of patient safety statistics and standards. Based on efficacy, a free market sales war of pharma vs. pharma would bring down the retail cost of drugs. Tort reform with patient acceptance of active and transparent continued drug testing during a post-release phase or phase IV, would induce even more retail competition and radically reduce drug production costs.

Pay-for-performance programs and other "quality" incentives must allow physicians the autonomy to make the best choices for individual patients and not confine them to the false premise of an "optimal care" concept that sacrifices quality to honor cost. Do not confuse increased medical quality to the patient with value for money to the payer.

Universal access to actual healthcare delivery must be assured, not universal access to waiting lists. Information technology should add transparency to common, user-friendly software that enables patient-authorized release and storage of all medical records through the Internet.

Patients have the ultimate power to control healthcare delivery expenses. Total disclosure of physician billing, fees and coverage availability is essential for patients to make informed decisions regarding healthcare delivery. Risk-bearing organizations also need to be transparent in their benefit packages and physician network offerings. Patients must be given informational tools so they can act on their own behalf.

Physicians must re-establish collegiality among themselves and with hospitals. The hospital once functioned as the social center of a doctor's life. Medical associations should work hand in hand with hospitals to foster the common goal of collegiality. Remuneration comes in many forms, not just in dollars: There is recognition, honor, gratitude and respect. From these emotional supports, physician charity is built and sustained. The heart of happiness resides in the right to freely do that which one does well. For me, happiness is making healthcare happen.

The views I express here are my own, and I am vitally interested in your opinions--whether or not they are consistent with mine. Tell me what you think. Call me at 213/683-9900 or e-mail me at president@lacmanet.org.