The elderly are all-too-witting pawns in this game of beggar--thy-young-neighbor doctoring. The old get older, consume more and more health care resources, and get older and older and seemingly never die. Politicans don't have the guts to confront the AARP's millions of votes, so the elderly continue to monopolize dollars through high-tech efforts to push the envelope of life expectancy. Medicare (read: your income taxes) pays a lot, co-insurance is cheap, so the old, like the insured, don't care.

Unfortunately, excessive care doesn't mean better care. In her book Medicine and Culture, Lynn Payer compared medical treatments in America, England, West Germany and France and found that American doctors are far more aggressive in prescribing and treating and testing and operating than their European counterparts. Sad to say, though, we are not healthier, and American medical care is no more effective than that of the less intrusive nations.

And for those without insurance, all the money the hospital has thrown into expensive technology is less than useless. It means--pure and simple--less money going to basic care for the needy.

The final place insurance crashes into care is in administration. We have many, many layers of billing for care. The government bills one way for Medicare, another for Medicaid, a third for veterans' benefits. Getting private insurers to pay for a medical procedure throws a Kafkaesque billing system into action. Bills run endlessly between hospital, insurer, doctor and patient.

According to the New England Journal of Medicine, the American health care system may waste as much as $100 billion annually on administrative costs.

The results of the system's scathing inequality, excess and waste are socially devastating.

Yes, our old people are living longer and longer, sustained by billions of dollars in drugs and billions more in ludicrous life-prolonging surgery. But our inner city hospitals are collapsing. Our infant mortality rate is shocking (the highest in the industrialized world). We are witnessing a revival of epidemics--not just AIDS, but measles, whooping cough and tuberculosis, diseases we thought were defeated, broken by the onward march of civilization.

We are approaching the point where most Americans, not just 37 million unlucky ones, won't be able to afford to be sick or get well.

INSTEAD OF TALKING about ideas, George Bush likes talking about paradigms. Here is another one for him to chew on.

Americans believe that police protection, fire protection, elementary and secondary education, and roads are public goods: The government has to provide them or we scream and yell. Before we can make any fundamental change in our health care system, we must acknowledge, decades behind the rest of the industrialized world, that health care is a public good, too.

What we need, and fast, is reform. Reform does not just mean cutting costs, or standardizing billing. It means changing the structure of America's health care system, root and branch. Any reform must accomplish three things. It must cut administrative costs. It must increase the use of preventive medicine. And it must cover the uninsured.

Any proposal for radical health care reform immediately runs into serious political problems.

The first is a tragic misperception. Politicians are afraid that Americans perceive reform as another case of handing stuff out to the poor. The politicians are wrong. All Americans--poor, rich and everyone in between--have begun to realize that health care, in the form of higher premiums, is killing them, too.

The second problem is that any major health care reform will cost lots and lots of money, and will require massive new taxes. Never mind that those new taxes will be the same money we are already spending on health care, Americans just don't believe the government can provide services as efficiently as the private sector.

This may not, in fact, be true. A number of studies suggest that Medicare is more efficient than private insurers in administrative costs.