What ails health care.

NOW are we ready to talk about health care?" asked Senator Hillary Clinton in the title of her New York Times op-ed last year. In fact, have we ever stopped talking about it? Medicare reform, prescription drug costs, the uninsured--these issues are much discussed. No wonder. A decade after Senate Majority Leader George Mitchell declared HillaryCare dead, polls suggest that Americans are more worried than ever about their health insurance. In a Market Strategies poll, 86 percent of people expressed deep concerns about rising costs and six out of ten regarded the likelihood of bankruptcy due to major illness as a serious problem.

That health care remains a major issue, though, is not due to a lack of effort on the part of American politicians, with bold efforts made to reform health care at the state and national levels. Washington expanded Medicare's scope and Medicaid's reach. The statehouses have worked furiously to help the insured and uninsured alike. And the health-care industry itself has gone though a massive reorganization, embracing managed care as a panacea and then rejecting it as a poison.

And, at the end of the day, we seem no further ahead than when Americans elected Governor Bill Clinton to the White House with a promise of health-care reform. Many of the problems remain the same: middle class angst, millions without insurance, double-digit spending increases. In fact, the situation has worsened: Health spending is at a historic high, consuming 15 percent of GDP. More Americans are without insurance. And those with insurance carry a greater burden--the typical worker now pays $750 more per year for insurance than just three years ago.

If the problems are familiar, so are the solutions proposed. While the grand design of the Clinton White House went unrealized, some type of national effort appears increasingly inviting. Just this summer, the National Coalition on Health Care, a bipartisan organization chaired by former Presidents Bush and Ford, announced support for a universal coverage scheme that would centralize key health decisions to a government committee. It's not that the coalition, comprised of big businesses like General Electric and AT&T, as well as union interests, holds a big-government bias. Rather, it's that the status quo appears untenable. So we're returning to the debates of the last decade: HillaryCare.

Perhaps that's not surprising. While the American healthcare system has gone through much "reform," relatively little of its overall economics has changed. Reform, thus, has largely been an exercise in shifting costs from payer to patient, from insurance plan to hospital, from hospital to physician, from uninsured to insured. Since the 1970s, much has been made of the idea of managing care--but really, these have been exercises in managing cost. For most Americans, the end result has been less control over basic health-care decisions, a prescription for universal dissatisfaction.

If we really want to address the system's shortcomings--to tame health inflation and broaden coverage--a new approach is needed. We must recognize that the structure of American health care is flawed, and we must seek to address this by giving people more control over their own health care.

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