This idea of a government-regulated private oligopoly system has the strength to be the compromise legislators eventually settle on.

Here, though, a partnership is between different levels of government is crucial. The federal government would fund vaccination programs, fund and administer an institution concerned with epidemics and set minimum standards. Those standards would mandate that state plans cover routine doctor visits and provide for a massive shift toward preventive care.

To save money there will, of course, be trade-offs. Heart transplants that cost hundreds of thousands of dollars, extend the lives of almost no one, and take away valuable resources from vastly more beneficial, if banal, activities like prenatal care, will be cut. Rationing will become an open element of the system. But the rationing will move away from its nasty classism toward a more rational ageism.

The brashness of open rationing is not entirely nasty. We have to realize that a longer life expectancy is not a universal good, that we would be a vastly healthier society if we tried to prevent suffering at the beginning of life than extend it at the end.

For those who have, America is the greatest place to be ill, and for those who don't, it is the worst. Usually, that's the end of the story, and we accept the triump of self-interest improperly understood. But this time, we actually have a chance to do something, and it could be a triumph of politics.

Instead of talking about ideas, George Bush likes paradigms. Here is another one for him to chew on...

We are nearing the point where most Americans won't be able to afford to be sick or get well.

...a nationalized system of health care, funded by tax dollars and provided through the HMOs.