In his State of the Union address, President Bush made references to the out-of-control costs of health care in this country. He overemphasized the need for reform and pushed his health savings account plan. The latter would fit in to his vision of an “ownership society,” where people spend their health care dollars more wisely if that money is their own. Unfortunately, these ideas are not founded in reality.

Medical malpractice consumes only around 1 percent of the health care dollars spent. More than 75 percent goes towards the cost of caring for chronic illnesses. There are few choices to be made when caring for a diabetic patient with high cholesterol, coronary artery disease, incipient blindness and early kidney failure.

We already have a de facto national health care system. Let me explain. We have already decided as a society that no emergency department can turn away a patient because they are unable to pay. We also have anti-dumping laws to prevent patient transfers based on inability to pay. The costs of providing indigent care then gets passed on to the insurer or HMO, and ultimately to all of us. It is like a “pop-up” game, where if you push down here, it pops up over there.

Bush would like lifestyle choices and the attendant costs to be borne by those who make the bad decisions to use tobacco, overeat, not exercise, etc. It implies that dear Aunt Lil, who did not have a health savings account, will be denied admission to the hospital when she shows up at the ER with crushing chest pain. Can that really be? I don’t see any other interpretation, unless you believe that her quadruple heart bypass will be paid for by re-possessing her home and retirement savings.

We are the only advanced society on earth that doesn’t have universal health care coverage (other than the de facto example I have given). Critics of such a proposal for the U.S.A. point to long waits and sub-standard care that is supposedly experienced by Canadians. Yet a very recent study of coronary artery disease outcomes in Canada showed equal or better results as compared with our system. Having a single entity to administer and pay for health care will eliminate the extra costs that insurance company middlemen create. All “for profit” health care should go the way of the dinosaurs — it is simply impossible to mix a profit motive and be an unbiased patient advocate at the same time. For-profit insurers, HMOs and hospitals, should be replaced by a single not-for-profit system.

Stanford University health economist Alan Einthoven has called private practice medicine “a license to print money.” When a third party insurance company is reimbursing for care, then unnecessary tests, procedures and surgeries are sometimes performed. I can give you an actual case from my own practice. A middle-aged woman was hospitalized for chest pain at a for-profit hospital in Solano County. For four days, tests were performed and aggressive treatment was given, yet her chest pain persisted. A cardiac catheterization was next on the plan, but she signed out of the hospital “against medical advice” because she thought the staff was running up the bill with unnecessary tests. It turns out her chest pain was caused by an inflamed esophagus, and was diagnosed with fifty cents worth of antacid and viscous lidocaine in my office. She had heartburn! Some for-profit hospitals love it when the admission diagnosis is “chest pain, rule out myocardial infarction” and another facility is footing the bill, because huge expenses can be justified.

I agree that some type of tort reform is needed, but that is not our biggest problem. Our health care system is simply old, outmoded and broken — many insurers will not pay for preventive care but will pay for the results of neglect and no care at all. Any laws and new programs that do not change the underlying system will simply throw good money after bad.

Kaiser Permanente is an excellent model for a not-for-profit system. Kaiser has its critics and some small portion of criticisms are justified, but I could find criticisms for all of the dozen hospitals I have been in as a result of my medical training.

Bush has ignored this problem that has been broken for years and instead focused on Social Security, claiming that a crisis is looming 40 years from now. His phony cost estimates were based on the assumption we would all live to be 150 years of age!

Mr. President, we need a national health care system now. Access to health care is a basic right like clean air and water. To deny health care to all hurts us all.

(Bosch lives in Napa.)