By Paul Hochfeld

Nationally, those who fear a government takeover of health care are reconsidering the recently passed reforms. In Oregon, meanwhile, Rep. Mike Dembrow, D-Portland, will be presenting a single-payer bill to to legislators in the upcoming session of the Legislature. I suggest we reframe the discussion by focusing on "value"and "risk pools."

Here are some facts. First, on health care, Americans spend twice as much per capita as the rest of the world's developed democracies. Second, by almost any measure of population statistics, our health outcomes are poor. Third, not only does 60 percent of our total health care spending flow through the government, but all private health insurance premiums are inflated by 10 to 15 percent to cover the cost of those who can't afford insurance. Additionally, since most health care coverage is employer-based, the prices we pay for virtually all of our domestically produced goods and services are inflated by a hidden health fee, which reimburses businesses for the cost of health insurance premiums for their employees. Undeniably, we're all paying for everybody already, and we aren't getting much value for it.

This is how our system works. We segregate the population into "risk pools" -- Medicare, Medicaid, veterans, Native Americans, employees (and their families). Because Medicare covers all of our elderly, it's a high-risk (expensive) pool. Similarly, Medicaid is expensive because it covers disabled people and the poor, who are high risk because of the adage that "health follows wealth." Veterans and Native Americans have their own special problems that make their health care expensive.

Interestingly, almost by design, while taxpayers foot the bill for all of the expensive risk pools, we also offer tax subsidies to insurance companies, who profit by covering employed people, who statistically are the healthiest, meaning those with the least expensive health care. And what about those who aren't in any of these defined risk pools? Today, most of them are uninsured.

When the uninsured get sick and end up in my emergency room, and then in the intensive-care unit, they can't pay their bills, meaning, as it stands now, we all pay for their health care. The Affordable Care Act fixes this problem with more subsidies to insurance companies. Not only is this an egregious taxpayer rippoff, but the direct costs and attendant chaos generated by dividing the country into sundry risk pools with a multitude of payers increases the total cost of health care by 20 percent.

As for finding value, in any given year, 20 percent of our population consumes 80 percent of our health care dollars. We underfund primary care and put financial barriers in the way of people receiving the timely, routine health care they need to keep them from slipping into the expensive 20 percent. In the meantime, health care providers profit handsomely from using very expensive technology to bring patients back from the brink of death and/or keep them alive to suffer longer.

For compelling reasons that are beyond the scope of this discussion, the multitude of payers and risk pools is the major impediment to re-creating our delivery system so that it focuses on improving the health of our patients and communities instead of focusing on the billable patient-provider encounter, as we do today.

The necessary, but insufficient first steps to sustainable health care reform is to recognize we are all paying for everybody already and put everybody in the same risk pool. It's not about smaller government or bigger government. It's about the government's fiduciary responsibility to make sure taxpayers get better value for the phenomenal amount of money we spend on health care.

Paul Hochfeld of Corvallis is an emergency room physician.

