The need to control costs, while ensuring health care for all Americans, now dominates every discussion about the future shape of medicine in America. This country must finally adopt some form of national health insurance, as every other industrial country in the world has long since done. It is a complex and a difficult issue, even without its political dimension, which often seems to render it almost insoluble.

But while the systems of other countries are not without their problems, the fact is that other industrialized nations spend less on health care and get more for their money. At the moment, our national debate on health care is in the phase of blame and recrimination. We are told that doctors are paid too much, or that lawyers and litigation cost too much, that pharmaceutical companies charge too much, and so on. But the truth is that everyone works within the constraints of the present system-and it is the system itself that must be changed.

One can draw an analogy to the earlier complaints about the cost and quality of American automobiles, which at one time were blamed on American workers. But the reality is that workers on the assembly line are prisoners of a system designed by others. Individual effort cannot significantly affect the outcome of the system. Only by changing the assembly line itself-by changing the way cars are designed and made-can a better product result. And given a better process, American workers have proven that they are as productive and efficient as anyone else.

Similarly, American medicine has grown up as an unplanned entrepreneurial system of individual providers. The current system does many things well, but at high cost. A growing proportion of that cost derives from legislation passed by American politicians, who are not accountable for costs they impose. Indeed, freedom from political accountability is one of the worst features of the present American system.