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Fix the costs first Health care can't simply be extended until its current ills are cured

First, do no harm. The Hippocratic Oath needs to hold true for politicians as much as it does for doctors. In the matter of health reform, that means controlling costs before expanding coverage.

The need for health reform is as plain as the headline on the front page of Tuesday's editions of The Buffalo News: "Salaried employees suffer loss of health care, reduced pensions due to Delphi bankruptcy." The system is falling apart. The wailing from the political right notwithstanding, without reform, we will have rationing.

But those on the left who continue to deny that controlling costs must be the first order of business need to read the same story. Today it's Delphi Corp. in Lockport, a company that is under severe economic strain. But as the costs of health care continue to soar -- reaching 20 percent of gross domestic product by 2017 -- more companies will find themselves under severe economic strain. Employer-based health care will become increasingly less available.

Whatever else anyone might want to do about health care -- universal coverage, public option, insurance co-ops -- it will come to naught if the spiraling costs of care aren't brought under control. And because it may be the only point in the debate that the political center of the country agrees upon, containing costs also will be necessary to win broad public support for any reform plan.

That's not to say that other goals are unimportant. With nearly 50 million Americans uninsured and medical costs driving the greatest share of the nation's bankruptcies, universal coverage must remain the goal, even if it is only for catastrophic costs.

Controlling costs will have to include a number of approaches, from preventing illness in the first place to reducing the practice of defensive medicine, to rewarding physicians based on outcomes rather than procedures.

We are, by choice, a largely unhealthy country. Americans eat poorly and don't exercise much at all. As a result, heart disease, high blood pressure, obesity and diabetes are nearly epidemic. The costs of treating these diseases are significant, yet their onset can be avoided through healthier choices, which insurers should reward through lower out-of-pocket costs.

Doctors, meanwhile, pressured by a litigious society and an inadequately constrained civil justice system, acknowledge that they order costly unnecessary tests to protect themselves from lawsuits. That drives up the costs of care, as do the costs of malpractice insurance, which are, in part, a function of a justice system that is focused too much on finding deep pockets and too little on assigning appropriate responsibility for bad outcomes.

Those factors, and more, must be attended to before the country can expand health insurance universally. Indeed, those on the left who hold up Canada's national system of health care as an example must also understand that malpractice lawsuits are much rarer there.

Without these kinds of approaches, we have little hope of expanding health coverage. With a carefully reasoned approach, the economy will grow and more people will be insured even as we continue to look for ways to provide universal coverage.

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