ESSAY

By Michael Kinsley

Washington is full of busy, self-important people, some of them actually important, but very few who would routinely keep you waiting 45 minutes in the anteroom for a long-scheduled 15-minute appointment. If the President himself left you twiddling your thumbs outside the Oval Office for three-quarters of an hour, you probably wouldn't mind -- but you probably would get an apology. Yet that kind of wait is common, without apology, when you visit a doctor's office.

There is no excuse for this. Other professions have meetings of unpredictable length and accommodate by not overbooking. Surgery and emergencies? Pshaw, the last time I squatted forever in a waiting room, it was for a dermatologist. The doctor keeps you waiting because he has power over you, like a bureaucrat in Bulgaria in the old days. Indeed, visiting the doctor's office is like a taste of socialism -- the crowded waiting room with little to read but hectoring posters, the feeling of helplessness, the endless forms to fill out. Which is ironic, since the typical doctor's office is the most free-enterprise corner of the most free-enterprise medical system in the advanced world.

Doctors' waiting rooms are hardly the most serious ailment of American health care. More than 30 million citizens have no health insurance at all. Few among the rest of us are free from fear of losing our insurance or finding it insufficient. Costs are soaring -- over 12% of GNP, by far the world's highest -- yet our longevity and infant-mortality rates are nothing to brag about. But an hour's wait to pay $120 for a few minutes of a doctor's time nicely illustrates how our system combines some of the worst aspects of both capitalism and socialism.

Although nobody has a kind word for socialism these days, virtually everyone is actually a socialist in principle when it comes to health care. If I were to say that every citizen is entitled to housing, supplied by the government if necessary, you'd peg me as some kind of liberal. If I were to say that every citizen is entitled to equally good housing, you'd peg me as some kind of nut. Yet that is more or less what everybody thinks -- quite rightly -- about health care. Is there a politician around who would dare to say publicly that the poor should get worse health care than the rich?

Of course the poor do get worse health care than the rich. Yet Americans don't have the efficiency benefits of the free market either. And it's not just because the government now pays for more than 40% of all health care. Private insurance also makes consumers relatively indifferent to the cost and quantity of medical services they buy. And even without insurance, who is going to price-shop for a heart surgeon or be able to judge whether some expensive lab test is really necessary?

Health care is one area in which the free market cannot provide either the universal availability that decency demands or the cost control that sanity requires. That's why even the conservative Heritage Foundation -- in an intriguing reform proposal billed as "market oriented" -- endorses a thinly disguised tax increase on the affluent, massive new government handouts to lower-income families and stiff new regulations on everyone.

The American Medical Association has its own scheme, called Health Access America, which includes most of the familiar nostrums. It would guarantee universal care through a combination of expanding government programs, enlarging tax subsidies and requiring employers to supply insurance. The A.M.A. has come a long way from the days when it hired Ronald Reagan to campaign against Medicare as socialism. Now an editorial in the A.M.A. Journal bizarrely blames the absence of universal coverage on "long-standing, systematic, institutionalized racial discrimination." Yet the A.M.A.'s reform plan is strangely reticent about cost control, without which fewer people, not more, will have access to decent health care.

America's health-care system needs to become both more socialist and more capitalist. The goal is socialist: equal, universal coverage. But the techniques of capitalism can make it possible. The private-sector health-care industry will not necessarily like these techniques. Doctors, hospitals, pharmaceutical companies and medical-equipment manufacturers have all thrived under the present worst-of-both-worlds system.

One example of a best-of-both-worlds technique is the Health Maintenance Organization. At an HMO, you pay one annual fee, and the group supplies all your health-care needs. Because the provider is also the insurer, there is no incentive to run up the tab with unnecessary services. Yet the HMO must compete for customers by offering high-quality care. And customers can comparison shop for price and quality at leisure when they're healthy, not in haste when they're sick.

Thirty-five million people are now enrolled in HMOs -- nearly four times as many as in 1980 -- despite misbegotten government policies that enrich doctors and reward patients for staying out of them. But HMOs suffer from an image problem. They are thought of as pseudosocialist bargain medicine. HMOs need to be "repositioned," as they say in the advertising game. They need a new image as supercapitalist medicine.

So here's a free idea for some medical entrepreneur. Give the HMOs snob appeal. Call the thing Executive Health Maintenance. Add a few cheap frills. Change the sales pitch. "Tired of schlepping from doctor's office to doctor's office, waiting around in squalid surroundings, filling out all those forms? Come to Executive Health Maintenance. We'll take care of everything. Not only do we have the best specialists, plus in-house lab tests and pharmacy, all in one convenient location. We have fresh coffee and croissants in the waiting room, as well as a fax machine, current issues of all the magazines and a concierge. And we promise you'll never have to wait more than 15 minutes, or the next organ transplant's on us."

It won't solve the health-care crisis, but it might help.