The Washington Post’s Robert J. Samuelson has seen the problem with the American health care finance system — it’s us:

Americans generally want their health care system to do three things: (1) provide needed care to all people, regardless of income; (2) maintain our freedom to pick doctors and their freedom to recommend the best care for us; and (3) control costs. The trouble is that these laudable goals aren’t compatible. We can have any two of them, but not all three. Everyone can get care with complete choice — but costs will explode, because patients and doctors have no reason to control them. We can control costs but only by denying care or limiting choices.
Disliking the inconsistencies, we hide them — to individuals. We subsidize employer-paid health insurance by excluding it from income taxes (the 2006 cost to government: an estimated $126 billion). Most workers don’t see the full costs of their health care; a reported Bush proposal to add new tax subsidies would magnify the effect. A similar blindness applies to Medicare recipients, whose costs are paid mainly by other people’s payroll taxes. Despite complaints about rising co-payments and deductibles, out-of-pocket costs are still falling as a share of all health spending. In 2004, they were 12.5 percent; in 1993, they were 15.8 percent.
We’re living in a fantasy world.

Given our inconsistent expectations, no health care system — not one completely run by government or one following “market” principles — can satisfy public opinion. Politicians and pundits can score cheap points by emphasizing one goal or another (insure the uninsured, cover drugs for Medicare recipients, expand “choice”) without facing the harder job: finding a better balance among competing goals.

. . . [Thus] the real problem is us. We demand the impossible. The changes we truly need are political. We need to reconnect people with the public consequences of their private acts. We should curb the subsidization of private insurance. Medicare recipients, especially wealthier ones, should pay more of their bills. But these changes won’t happen because people don’t want to see the costs. We don’t have the health care system we need, but we do have the one we deserve.

Mr. Samuelson is spot on, so read his entire piece. My sense is that making care available to people regardless of income is an achievable goal, although American society will probably always struggle with the problem of inducing an optimal number of citizens to take personal responsibility for preventive care. But what really makes health care finance reform difficult is the political preoccupation with keeping citizens insulated from the true cost of health care through providing subsidies in the guise of health “insurance.” Until that changes, Samuelson is right — politicians will continue to play political football with the perks of the existing disjointed health care finance system without facing the knotty problem of balancing the competing goals of a well-conceived system.