DR. EISENBERG: Let me add something to that. The idea of contracting for managed care organizations and having bids was described by Miller in that New Republic article as having come out of the Physician Payment Review Commission (PPRC). So I must state that it was developed beautifully by the PPRC staff and is described in last year's annual report. We will see if anyone decides to take it up. It is a risky but interesting idea.

DR. JOHNS: I am Mike Johns from Johns Hopkins. I am interested in understanding how the marketplace is going to accommodate the ever-expanding numbers of uninsured. Although there seems to be a sense that shifting government health dollars to the states will allow them to spread those dollars further, I expect that more people will drop off the roles and there will be an increasing number of uninsured. Somebody ultimately bears the cost of that, generally the middle class in some way.

How will this system deal with that? Will there be any sense of accountability? For example, these physician groups that you talk about—the new entrepreneurial physicians that we see coming together—will they be willing to take on the responsibility for some of these populations? Will anybody be able to afford to take on those responsibilities? Who is going to step up to the plate?

DR. GOLDSMITH: The system that we have now gives academic health centers and urban public hospitals the quasi-governmental responsibility of taxing the rest of the health care system to pay for services provided to the uninsured. I agree that there is nothing in the current round of "reforms" that is going to do anything other than increase the number of people who are not covered. I think this is fundamentally irresponsible, flawed social policy.

You could argue from a strategic point of view that the federal government is now the principal driver in health cost inflation in the United States. President Clinton's spirited defense of a double-digit rate of increase in public spending for two public health financing programs is not adding anything to the debate over how to get more affordable care for the population that is uninsured. I do not see the private sector leaping forward to take responsibility for these folks, and if public costs continue rising at the present double-digit rate, we won't get an affordable federal or state response to the problem of the uninsured.

Yet I do think there are opportunities to pool the purchasing power of individual and small group health insurers and give them the same kind of per capita cost advantage that large employers enjoy. We are not going to get very far in solving this problem without revisiting the health policy debate. With hope, we will not waste as much time as we have in the last two years.

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