Presidential address: Discovering the right questions—Our call to action—Who will define health care rationing, and how?☆☆☆

Abstract Will the citizens and legislators of our country be accurately informed in enough detail to decide wisely on the proposed health care plans? If we cannot afford all health care for all people, how can we make the government use the words "rationing health care" and be certain that the rationing is done by the stakeholders (patients and providers)? Changes in the health care system are needed and it must be improved, but does that justify totally changing a system providing the best care in the world for 200 million people? Or should we build on and improve that which is good and extend it to the remaining 10–15% who are currently without insurance? Can the government guarantee good health? Does this imply we are to guarantee health, then food, and then housing and clothing? Or, rather, should we guarantee the right to pursue a job that allows the purchase of health care insurance, just as we have the right to purchase housing, food, and clothing? Can we guarantee health to our citizens, or must we guarantee the right to pursue good health? How much should we spend on health care? Is the health care industry a growth industry with the product a healthier population? If so, should it be punished or encouraged? Is what we spend out of line with what is spent on entertainment, tobacco, and alcohol? When viewed from that perspective is health care too expensive or a bargain? Will the individual citizen accept his/her individual obligation to change habits and lifestyle? Do the people of this country really want a health care service with the regulatory simplicity of the tax law, the frugality of the Pentagon, the efficiency of the Post Office, and the compassion of the IRS? To be consistent with the Vice President's efforts to downsize government should government involvement in health care be increased or decreased? Are the proper innovations underway on the state level? Is federal law necessary now at all, or should Washington just monitor the emerging new programs at the regional and state levels? If England and Sweden are backing away from socialism and starting to privatize, and if major cities in our own country are acknowledging governmental failure and inability to deliver cost-effective quality service for such simple things as trash collection and maintenance of park systems, how can our federal government run health care? What can we learn from the Rochester, NY health care system and from Oregon about empowering the stakeholders in a system of regional control? How can we foster the Integrated Delivery System concept? How can we empower the patients, the hospitals, and the physicians to make these decisions locally and regionally, without politician and government interference and without oppressive government micromanaging regulations? If health care professionals are not responsible for the societal disruptions of drug abuse, AIDS, crack babies, violence, alcohol, and tobacco, should the government's cost analysis charge these costs to a health care budget, or are they better charged against social program budgets? If we subtract all these costs resulting from violence, AIDS, drugs, alcohol, highway speeding, etc., and subtract the cost savings from meaningful tort reform, would our health care costs be increasing at less than inflation? If so, are our health care costs as adjusted for liability, population demographics, drugs, violence, etc., growing faster or slower than those of Canada and Germany? Which penalizes our industry more in national and international sales competition—the cost of health care or product liability? Will increasing primary care cost more money than it saves? Who will pay for the necessary increased educational costs in medical school and residencies for those primary care physicians? Who will pay for the continuing medical education? Nurse clinicians and physician assistant cost less; should they fulfill a very simple level of primary care and triage patients to specialists for proper definitive care? Would it be more cost-effective and better quality care to eliminate the generalist physician? Is the true generalist physician with today's complex medical knowledge an impossibility, like the solo violinist trying to play Beethoven's fifth all by him/herself? Will this country look at long-term cost-benefit analysis of medical research? Will this country provide legal relief from product liability and for new and emerging health care research products and technologies? How much can society save by investing in good medical research and in good health care?