We also could do more to help finance the education of doctors. And, of course (am I dreaming?) we could enact badly needed tort reform to stop the more unscrupulous trial lawyers from acting as parasites on our medical system. And, as many have proposed, we could allow customers to shop across state lines for the best private policy. (And we can continue the HSAs--health care savings accounts--that are so popular with young people.) Upgrading and truly "reforming" the existing system might be costly, but not nearly as costly as inventing a whole new bureaucracy.

If someone lacks his own insurance and has a major illness, let him see a public doctor or a publicly-supported doctor. The care may not be as good as the privately insured receive (though in some cases it might even be better, as trauma patients can testify in Seattle's Harborview Center), but it will be better than people receive in most of the world, including the developed world. Meanwhile, by not mixing the public and private systems, there is less danger of the private system gradually being taken over by the government.

This "reform the present system" approach would address all three main concerns Mr. Douthat raises, and two more. It would not cause a rise in private premiums (his first concern), as the plans now before Congress would do. Second, it would raise the federal government's expenses in health care, but not as much as under the proposed Congressional bills. Third, it could care for ALL the currently uninsured, including even several million people in society who are so disorganized or anti-social that they would not bother to apply for or carry a "free" insurance policy.

The limited federal free care choice could provide modest preventive care treatments, including an annual check up, but only if the recipient is willing to wait in line--as he or she would do anyhow in most socialist systems. Long term inculcation of preventive care goes on already in our public school system and that perhaps could be improved.

There are flaws in this approach, of course. For example, it lacks a method to control costs over time in the (uninsured) public health sector. (A co-pay based on ability-to-pay would help, even if only modestly.) But, the concept's flaws are less, in any case, than the alternative, which is a slow socialization of medicine in America, with all that entails. Most Americans would not settle for the public free choice and would continue to pay for something better.

This brings me to the issues Mr. Douthat does not address--nor could he, of course, in a column-length piece. A fast march to socialization, or a slow one, will produce rationing. There is no way to get around it. And the social justice lions who roar for a "single payer" system--who, as typical Americans used to thinking of themselves as special--will be among the first to become indignant when it is their mother or their child that is deprived of adequate care in a timely fashion under the socialist system.

The way around rationing is competition, and competition will occur only in a private system that allows doctors, hospitals, insurance companies and pharmaceutical companies to make a profit. The Administration's spiteful attacks on these elements in the current health care system are shocking in their crude and apparently ideological unfairness. More than anything, the tone of these assaults betrays the long term intention to promote a government takeover. Rationing, as I say, will be the result.

Rationing makes outstanding care less likely. Sometimes it is a killer. It doesn't always deprive the old and sick of choices and options, but it often does. In Europe it frightens people away from hospitals where doctors and "ethics panels" have the right to withdraw care without permission or where pressure might be applied to patients and their families. Even for those not at death's door, rationing can mean painful, dangerous delays. Since the patient is not even remotely regarded as a customer, he has no power in these dealings. If you dislike insurance company bureaucrats, wait until they are turned into government bureaucrats.

Second, socialized medicine, by stigmatizing private profit and promoting arbitrary controls on costs, decreases innovation. Under the present U.S. system new operation techniques and other technologies may help the privileged few at first, but then they are mainstreamed to the whole population. American medicine is the best in the world for those who can afford it. If it bothers you that the rich can seek out "the best specialist" at Mayo (for example), that only means that you to level the care to the median, based on some truly misbegotten social value that doesn't consider long term consequences. If a billionaire's expensive treatments provides fat profits for his care givers and pharmaceutical companies, why should you and I object, if the result is that the same techniques and products are available in a few years--and benefit--everyone? The best innovations in most fields are expensive at first and require customers who can front the initially high cost.

True, the average person in our diverse American society--a society with a large immigrant population and with a culture of immoderate consumerism that cannot, however, be blamed on the medical community--does not live as long as does the average person in Europe or Japan. But decade by decade the average person here is living longer, nonetheless--largely because of our medical community--and the innovations of our free system benefit them and whole world, including the rest of the developed world.

Much of the rest of the world are free riders on our private system. We innovate, and pay for it, then others also benefit. When the United States decides to make this system unworkable....when we compound our present doctor shortage by making a doctor's economic career miserable...when we drive insurance companies out of business...when we strip the profits out of huge pharmaceutical companies' investment opportunities, causing them to hold back on experiments...when we continue to allow trial lawyers opportunistically to sue everyone in the medical system to provide compensation to the handful of patients that are mistreated, and thereby raise the cost of the system overall...then how will our children and the children of the rest of the world get the new health improvements that are on the horizon?

There is no reason to lose the leadership heritage of American medicine, no reason to throw over a system whose success is exported to the whole world. Sensible reform is available.