Since publication of the American College of Physicians' (ACP) position paper "Universal Insurance for American Health Care" [1], the College has received many supportive letters and phone calls along with others expressing concerns about the proposal.

In the sample of letters published here, several issues stand out: Will practicing within the limits of a national health care budget require unfair financial sacrifice by physicians, particularly primary care physicians? How will the budget control costs without stopping the flow of money if the budget is exceeded? Will innovation and excellence be hampered? Will the ACP plan result in a centralized bureaucracy even more oppressive than the current situation?

The ACP position rejects perpetuation of the current inequities in physician reimbursement. The College recognizes that the new Medicare fee schedule (RBRVS) has not yet achieved the benefits expected for internists who perform mainly evaluation and management services. Under the College's plan, fees would be negotiated between physicians and payers, and the fee schedule would fairly reimburse evaluation and management services. In no way do we advocate relinquishing participation in fee setting to a government bureaucracy acting unilaterally.

Budgeting is a device for planning and financial discipline; it should not bring health services to an abrupt halt by cutting off cash flow. If budgets are exceeded because of an increase in disease burden, such as the human immunodeficiency virus (HIV) epidemic, these expenditures must be supported. If funds allocated for health care are exceeded because of unnecessary use of services or inefficient use of technology, this overutilization must be curtailed in future years through adjustments in the payment system.

The ACP plan would sustain innovation and excellence. Organizational innovation and practice efficiency would be fostered by insurance reforms that encourage competition among health plans based on price and quality rather than through the avoidance of sick people. The plan also calls for increased funding for education and research, with support from both public and private payers.

Although the ACP plan calls for a representative national health care commission—as do most plans, including managed competition—this commission would not become a burdensome bureaucracy. Rather, it would set budgets and establish national guidelines for how the system would work. States and regions would administer the system, with local input and control.

Some writers expressed concern that the College membership was not sufficiently involved in the development of the College's health care reform position. Every member of the College was invited to join a network of physicians who assisted in the policy development, and 4500 signed up. Through their ACP governors, network members were invited to comment on early drafts and discuss the positions as they evolved. Comment was also received from dozens of regional meetings and from groups outside the College. Articles and progress reports appeared in virtually every issue of ACP Observer. This extensive consultation with the membership influenced policy development by the Board of Regents of the College.

The system of health care envisioned by the College asks a lot of everyone: physicians, patients, insurers, business, and government. It seeks change not for its own sake but because the people of the United States have made clear that a system that insures fewer and fewer and costs more and more cannot persist. The ACP plan puts a premium on the very ethic that is central to the practice of medicine: do all that should be done to preserve life and improve its quality by extending all medically necessary and appropriate care to everyone. To achieve this goal, cost control is needed. Physicians' participation on the high road provides us the credibility necessary to maintain a direct hand in the implementation of the new system, to maintain quality without case-by-case second-guessing, and to re-establish the role of the physician at the center of the nation's new health care system.