Most discussions about health care reform focus on efforts to expand the number of people who are covered by health insurance. Yet the current system does not work well even for those who do have coverage. Costs continue to rise at an unsustainable rate even though health plans increasingly shift costs to patients and restrict coverage.1 For Medicare, the focus of cost control is largely on fee constraints, which has led to a shortage of primary care physicians, further exacerbating cost pressures.2 Making sure that no one is denied access to needed care is an ethical imperative; ensuring that we can collectively afford the cost of such care is a political necessity.

A government-run system promises administrative simplicity but lacks the tools to slow the rate of growth in costs. Chronically underfunded public agencies are not equipped to assess rapidly changing medical technology in a timely manner. Manufacturers and other special-interest groups will continue to dominate the decision-making process. Since Medicare has been unable to slow the rate of growth in costs, how would a single-payer system be more effective, given our political system, especially when the stakes for special-interest groups are even higher?

Encouraging competition among health plans, even if one of them is "public," will also fail to solve the cost problem. With the exception of highly integrated organizations, such as Kaiser Permanente, health plans have only two tools to control costs: financial disincentives for patients and fee reductions for providers. Acceptable out-of-pocket maximums, however, vitiate economic incentives to restrain use, particularly for expensive care such as inpatient care. Unable to alter provider behavior, health plans primarily try to avoid enrolling people who are likely to need costly care.