The current discussion of Health Policy is so exciting and the McCain and Obama plans are so different that it is easy to lose sight of the long run problems/opportunities that face our health care system. Wonks Anonymous believes that we will need major changes in the way that health care is produced and administered before we can really begin to deal with our poor health outcomes and unusually high medical costs.

Of course the current fight is important. We have the stark choice of patching a system that does not work all that well or attempting a radical change in health care finance, which change appears to have been designed in Cloud Cuckoo Land or some other location where common sense and a grasp of reality are entirely absent. Still we need to plan for the future.

Wonks Anonymous believes that future improvements in the performance of our health care system will have to come from hospitals, clinics, doctors and others who produce health care. He has no faith in health insurers to accomplish any real change. They are almost entirely ignorant of the actual problems in health care, they are unrestrained by professional ethics and their relationship with consumers of health care is entirely bureaucratic.

To see what we have to work with we need to examine the two systems of health care delivery now found in the US.

There are two systems?

First we have the conventional model: many doctors, working alone or in small groups, hospitals, clinics and other providers who are all loosely coordinated. Providers are paid for services - treatments, days in hospital etc. Patients with some help from their doctor - if they have a doctor- are expected to decide where to seek treatment and what treatments to get.

Most discussions of the conventional model - let us call it the square - are based on the fiction that the patient is really in charge. Consequently most discussions of rising health care costs attempt to show that the patient is the cause. The solutions that come out of these discussions most often involve charging prospective patients large amounts of money out of pocket before they can have unrestricted access to the health care system. This is supposed to encourage patients to lower their demand for unneeded care, investigate potential treatments and hospitals and then wisely choose the optimal care.

We do, however, have another model: In this model a large medical group - a doctors cooperative if you will - contracts to provide coordinated care for individuals and groups. The cooperative may also create an insurance subsidiary to market health coverage and assure adequate reserves  and a hospital subsidiary that runs hospitals for the patients of the medical group. Coordination in this model is built into the system. The patient "belongs" to the entire group from the family doctor to the neurosurgeon. One doctor's careless mistake damages the reputation of the entire group.

In this model - shall we call it the circle - the patient has one major decision: Does he or she trust the medical group and his or her personal physician? The patient has no need to worry about the financial costs of treatment since everything has been taken care of in advance by membership dues.

Doctors in this model have direst incentives for cost savings - they get better pay if the medical group can bring costs below the membership dues. They are also trained professionals who have absorbed a strong professional ethic along with their training.  This ethic restrains the excesses of cost control and tends to drive the people in the insurance subsidiary crazy. Doctors also have the best information on what can and should be done to provide quality care at the lowest possible cost.

Such a model - or to be more accurate an imperfect approximation of such a model - actually exists on the Left Coast of the United States. It was started by Henry J Kaiser and Dr. Sydney Garfield during the Great Depression and has continued to this day, mainly in California as Kaiser Permanente with some branches in the Pacific Northwest - The Group Health Cooperative of Seattle -  and in other parts of the country.

It is Wonks Anonymous opinion that this second model of care, prepaid group practice, has great potential to improve the performance and economy of our health care system. Unfortunately this model is also least suited to survive the current round of creative destruction sweeping health care. A doctors cooperative is strongly influenced by medical notions - ethics, good practice and so on - and these medical notions seem to slow it in the race to the bottom that is the modern health insurance market.

Tomorrow: How do you fit a round peg into a square hole?