The undersigned are writing as individual internists, as ACP members, and as members of the Board of Censors of the Medical Association of the State of Alabama, by action of the Board on 16 September 1992.

We appreciate the time and deliberations that went into the preparations of the ACP report. It describes the current situation eloquently and accurately in many details. However we disagree that the conclusions and recommendations derive from a consensus of the grass-roots membership of ACP or that "input from a network of 4500 ACP members" somehow constituted a general endorsement when these "inputs" must have been fragmentary at best.

That the authorship of a policy so revolutionary in scope is limited to the authors, Regents, and other officers signing the endorsing editorial is important. Stories generated by the ACP press release drew the logical inference that the position paper had the support of 77 000 members of "the nation's largest medical specialty society" (The Times) and that the article represented "an extraordinary change of heart" (The Wall Street Journal).

By contrast, the American Medical Association (AMA) has made it clear that JAMA Editor George D. Lundberg, MD, in endorsing the concept of global health care budgets in the May 13 issue of JAMA, was exercising his editorial prerogative, contrary to the policy of the AMA. The ACP never put the policy to the membership as a plebiscite and we are not convinced that the authors or the Board of Regents had "the consent of the governed," as there should be in a matter so crucial to the future of the American health care system.

We entirely agree with the statement that "government may be efficient at some functions, like collecting taxes and writing checks, but it is not well suited to administer and oversee the complicated set of interactions in the health care system." Where we part company is in the extraordinary leap to a Canadian-flavored system of a national health care commission undergirded by poorly defined state negotiation mechanisms.

The belief that federal government can be kept out of medical decision making, despite empowering it with command and control authority, and that sweet reason will prevail in the states is incredibly naive. Eagerly granting the federal government power to determine how much to spend on health care, what services are covered, and total control over the quantity and distribution of physicians is a blueprint for disaster.

We agree wholeheartedly with the authors' righteous indignation over third-party intruders in the practice of medicine. Yet, astonishing confidence is placed in remedying this outrage by shackling doctors, by fixing fees, and by requiring mandatory assignment for both public and private patients.

The remainder of the 20th century will be marked by draconian cuts in services. If the immediate past is any guide, health care will be first on the chopping block. In the private sector, business and industry will continue to lament that the nation's vital interests are threatened by the health care component of U.S. products, pricing them out of competition in world markets. The solution will be to ration patient care.

Any Americans who would willingly handcuff themselves to such a future, would be properly scorned as fools. We do not believe that most ACP members can be so characterized.