Recent months have seen five states roll out ambitious plans for health-care reform. Fed up with the failure of the federal government to deal with the linked problems of poorly designed delivery systems, rapidly rising costs and increases in the number of people without access to health-insurance coverage and care, these states have launched initiatives to change the financing of health care.

Daniel Marsula, Post-Gazette Related coverage A promising prescription for Pennsylvania Rendell takes a wrong turn Just a first step A bigger role for nurse practitioners Previous coverage From the Jan. 21 Forum: Rendell's remedy / Sandra Fox Rendell's remedy / Andrea R. Fox and Jessica Seabury

Unfortunately, the four states whose plans preceded Pennsylvania's address symptoms rather than causes. Without fixing the way health care is delivered, financing solutions are just a game of Three-card Monte, shuffling dollars from one pocket to another without asking why we are paying for systems and activities that do not contribute to health.

Gov. Ed Rendell and his team in the Office of Health Care Reform have proposed the best plan yet: a set of interrelated proposals that consider the whole system and speak the truth about the core principles that need to be addressed to get patients what they need and to enable us to afford access to care for all Pennsylvanians. This plan still falls short of what is necessary to eliminate the 50-percent of health-care spending that is wasted, which could change the entire conversation, but it goes the furthest and pulls some of government's most powerful levers to address the systemic problems at the root of health-care's deepest failures.

In analyzing the governor's "Prescription for Pennsylvania," the public and legislators should stay focused on core principles:

The public should not pay for care that does not produce the desired results due to medical errors. When buying a car you pay for the quality of the ultimate product, not for the component work (expert designers, welders, electricians, line workers). In health care, the product is the outcome of a surgery or medical intervention, not the dis-integrated work (surgeon's time, physician's time, gauze, medications, etc.). The governor's plan recognizes this and starts by refusing to pay for medical errors (lemons) while designing more sophisticated ways of paying for performance. This should provide hospitals and physician groups the incentive to focus on eliminating unsafe conditions for patients and workers.

		Geoff Webster is a principal with Value Capture, a health care consulting group based on the North Side, and a member of the Governor's Advisory Panel on Health Care (gwebster@ valuecapturellc.com). He is a former director of the Pittsburgh Regional Healthcare Initiative and the Consumer Health Coalition.

The cost of insurance coverage for employees is part of their total compensation, despite illusions to the contrary. Other states have made the mistake of requiring businesses to pay an insubstantial share to reform health care, essentially taking away compensation earned by employees and shifting the burden of these costs to the taxpayer. Businesses must be required to keep their money in the system (or start putting it in, in the case of the "free riders" who are not holding up their end of the social bargain). The Prescription for Pennsylvania deals with this problem by imposing a "play or pay" mandate for businesses to either cover their employees or pay a payroll tax that enforces a contribution to the system. However, it also recognizes that some businesses are too small or unprofitable to sustain this cost and offers subsidies for these businesses on a sliding scale.

People who can afford health care for themselves and their families should pay for it. It does not make sense for other Pennsylvanians to contribute to the coverage of people who can buy it, and it does not make sense to build in the inefficiency of collecting taxes from these people, only to buy them coverage they could have bought themselves. The Rendell plan recognizes this by proposing an individual mandate to purchase insurance coverage, while creating a tax-subsidized mechanism to make health care affordable for people who have little or no income.

Insurers defy the core idea of insurance (spreading financial risk across a broad group of people) when they adjust rates based on demographics and health status. Today, insurers essentially "cherry pick" the healthiest people they can, which causes rates to be high for the sickest people and the smallest businesses. The governor's plan deals with this by mandating "community rating" in the small-group and individual-insurance markets.

Every resident of the commonwealth (and indeed the United States) should have access to the care they need. The governor's plan should make affordable care available to almost everyone.

The Rendell plan makes many other wise recommendations, such as rationalizing the purchase of expensive medical equipment, reducing emergency room use by making less expensive care available 24/7, removing limitations on health professionals so they can practice up to the level of their training, requiring interoperable electronic medical records and advancing wellness through measures such as mandating smoke-free workplaces.

The introduction of a plan is not the same thing as creating better health care for every Pennsylvanian, however. Therefore, I urge the public and the state Legislature to treat this plan as an integrated whole and to debate the entire package, as opposed to the pieces. As a sometimes skeptical member of the advisory group that suggested many of these recommendations, I would like to congratulate the administration for its vision in advancing this promising proposal.