The long-awaited position paper [1] represents several years' work and the input of many ACP members. It is a comprehensive plan and makes valuable contributions to the current debate, particularly in the areas of insurance and tort reform. Topics not often discussed, such as financing of graduate medical education and basic health research, are welcome additions. The crucial section on controlling costs, however, contains serious flaws that undermine the overall plan.

Heavy reliance is placed on central planning to allocate resources and on price controls to help keep costs within a global budget. These methods have failed miserably in the former Soviet Union and other Eastern Bloc countries constrained to practice socialism. No reason exists to expect that American central planners will have any more success than did their Soviet counterparts. The distribution of health care is a complicated enterprise, involving thousands of hospitals, private companies, providers, and hundreds of millions of people. Further involvement of a central bureaucracy in this process will probably result in a lower standard of health care delivery and significant cost increases [2]. Price controls will make certain undervalued procedures virtually unavailable (for example, office visits for Medicaid patients) and will result in "rationing by queues" [3].

Giving the government more power to set prices for medical services is unwise, especially in light of past governmental performance. Given arbitrary Medicare rate freezes, the enactment of the horrible RBRVS, and so on, a case can be made for limiting the role of government in this arena, not enlarging it. Do we really want to spend our valuable time and energy in constant "negotiation" with government agencies over the price of services?

The determination of "medically effective and appropriate care" is often difficult. The concept of central control here is troubling. Decisions about care are best made within the context of the doctor-patient relationship. A highly trained physician and an educated patient working together will make a decision that is "appropriate" in most cases. Practice guidelines are commendable as an educational tool, but their institutionalization would promote the practice of "cookbook" medicine. This would result in inappropriate care in specific instances and discourage originality and individualism, characteristics in which physicians once took pride.

The position paper focuses on controlling physician fees (that is, income), but this does not address the problem of controlling the rate of rise of the overall health care budget. Physician income has remained at 15% to 20% of the total health budget and has not risen disproportionately. Most cost increases are due to government-mandated administrative expenses and high-cost technology, the use of which is driven by the need to defend against the threat of malpractice litigation.

Why focus attention on physician income? The ACP is taking the "politically correct" position of nobly accepting income limitation on behalf of its members to promote the worthy goal of universal access to health care. Unfortunately, such a stance will hurt our profession and will ultimately have an adverse effect on quality of care. Physicians endure long years of rigorous training and deferred income generation. They enter peak productivity some 5 to 10 years later than their contemporaries, often with considerable debt. They work 50 to 100-hour weeks with on-call responsibilities and are under a constant burden of stress that few people outside the profession understand. Most physicians are not in it for the money, but many would probably not have elected to pursue medicine if they knew that their income would be capped. With Medicare freezes and cuts, we are already working harder for less.

It should come as no surprise that medical school enrollment is down and that the overall quality of students entering medical training has declined in recent years. This should be of critical concern to the College because internal medicine has lost considerable ground in its ability to attract the brightest candidates. The answer is not to redistribute income from surgeons to internists or from subspecialists to generalists. Rather, we should work together to enhance the standing of the profession as a whole. I would like to hear the College state unambiguously that physicians deserve to be highly compensated and that a high level of compensation will assure that American physicians will continue to be the world's best.

Enactment of the plan's insurance, administrative and tort reforms would reduce overall costs without cutting into quality medical care. Use of copayments would decrease patient demand for certain services. Financing of insurance coverage for all is within reach, using some combination of tax credits, vouchers, employer contributions, and direct payment by those who can pay. It is both unnecessary and unwise to create a massive, government-run, single-payer system. It is undesirable and unnecessary to ration medical care. It is unfair and counterproductive to balance the health care budget on the backs of practicing physicians.