Suzi Wizowaty

What's keeping me awake at night these days is the growing sense that, with repect to health care reform, we're avoiding the most important, and the hardest, question.

I suppose we're trying. After all, we do talk about "containing costs." But what do we mean? Which costs? Whose costs?

Pharmaceutical costs? The cost of a hospital stay or a particular out-patient procedure? Insurance premiums? Indeed we rail at all these expenses. We wish they were less. We find them outrageous. And some of them are. And it's true, we need to have a country-wide conversation about the role of profit in health care.

But I think underneath all this is a sense of entitlement, and expectation. What we really mean when we talk about containing costs is that when we get sick, we want everything possible done for us to make us well, and we don't want it to bankrupt us. You could say we don't want it to cost us an arm and a leg. You could say we don't actually want it to cost us very much at all. In fact, if we have insurance, we think insurance should pay for it. And if we're poor or uninsured, we think somebody else who has money should pay for it--the hospital, the state, somebody. Certainly not us.

This is a problem. Why?

First, there is no "somebody else." There is only us. People, living in communities, who have to pay the costs of the health care system, directly or indirectly, one way or another, through increased premiums, broad-based taxes or some other strategy. It still comes from us.

Second, health insurers must take in more than they pay out. That's how insurance functions. This works for home insurance; with any luck you'll never have a fire. This will not work by definition for health care: we are all going to die. With very few exceptions, we will get sick before we die, and in our last months or years we will rack up medical costs that will make our loved ones nearly as unhappy as their impending loss.

We have three basic choices. We can say that only those who can afford health care can get it--i.e. the "system" we have now--and everyone else can compete for the limited charity care that emergency rooms provide, and know they're likely to die sooner than they would otherwise. Or we can agree that, yes, we're all entitled to every possible intervention, and we're going to pay for it together, whatever it takes, even if it requires almost our entire GDP, which it eventually will--which is where we're headed without acknowledging it. Or, we can have a hard conversation about a limited amount of health care everyone is entitled to, which we'll pay for as a society according to our means, and everything beyond that will be up for grabs--for those who can pay. What this limited care should be will require endless negotiation and will change continually--and it should, and the more people who participate, the better. It will never satisfy everyone, but it can be a vigorous expression of our democracy.

Many people believe that virtually all of the industrialized world's health care systems function better than ours, and we could learn a lot from them. Perhaps the most important thing we could learn, which we seem so desperately afraid of, is that we cannot have everything we want all the time. Every single system in the world sets limits. Americans don't like limits. When we do face this issue, the real question will be, which limits are the most fair?