A dozen years after Bill Clinton’s health reform
efforts were destroyed by the insurance industry’s
duplicity, it’s worth trying again. The health care
system is steadily becoming more gummed up in ways
that are impossible to hide.

One of the bumper stickers attacking the Clinton plan
read: ”If You Like the Post Office, You’ll Love
National Health Insurance.” That wouldn’t work today:
the Postal Service runs a system that is manifestly
more rational and efficient than our health care
system. For starters, imagine a postal system that
refused to deliver letters to or from 45 million
Americans — except on rare occasions, by ambulance.

”This is one of those fleeting opportunities where a
catastrophe creates an opportunity to rebuild
something better than before,” says Dr. Irwin
Redlener, president of the Children’s Health Fund and
associate dean of the Mailman School of Public Health
at Columbia University.

In a sign of the growing disenchantment with our
health system, 13,000 doctors have joined Physicians
for a National Health Program, which lobbies for a
single-payer government-financed health program.

There are four main problems with the existing system.
First, it leaves out 45 million uninsured Americans,
and their number is rising. Second, it is by far the
most expensive in the world, costing 15 percent of our
national income, yet our outcomes are awful — U.S.
life expectancy is worse than Costa Rica’s. Third, our
business competitiveness is undermined when, for
example, medical expenses add $1,500 to the sticker of
each General Motors car. Fourth, our system is
catastrophically inefficient: according to a study in
The New England Journal of Medicine, health
administrative costs are $1,059 per capita in the
U.S., and just $307 in Canada.

A single-payer system would be most efficient but
probably is not politically feasible at the moment.
The smart new book ”The Health Care Mess” suggests a
variety of more gradual approaches that would face
less opposition.

Whatever the mechanism, all children should be
covered. It’s a disgrace that we use public funds to
save the lives of nonagenarians but not those of
9-year-olds. And kids are a bargain: per capita
medical spending is $1,525 for children less than 5,
and $9,000 per person aged 65 to 74.

A second principle is that we should put less emphasis
on curative medicine and more on public health and
prevention — everything from preparing for avian flu
to encouraging exercise. Sure, we can buy more ”left
ventricular assist devices,” which cost $210,000 per
patient installed, or buy Erbitux for colon cancer, at
$17,000 per month of treatment. But as a wise new
book, ”Prescription for a Healthy Nation,” argues,
you get more bang for the buck when you promote
healthier lifestyles — fighting obesity, cigarette
smoking and the like.

Raising cigarette taxes saved far more American lives,
for example, than an army of neurologists ever could.
In the same spirit, I’d like to see a French-fry tax.
And imagine the health gains if we banned potato chips
and soda from schools.

Reforming the health system won’t be easy. In the real
world, poor kids don’t see doctors not only because
they’re uninsured, but also because Mom doesn’t have a
car, can’t easily get time off from work, or doesn’t
speak English. Those are hard nuts to crack — but one
reason to think that we can do better is that much of
the world does better.

I’ve been thinking of health care partly because of
something that happened when I was on vacation in
August. My kids and I were stacking firewood for my
parents on the Yamhill, Ore., farm where I grew up,
when suddenly the seven-foot stack collapsed — on top
of my youngest. She was knocked down and pinned, her
face bleeding, under a pile of logs.