President Obama told Congress he would not sign a health care bill that added any amount to the national debt — a criterion he does not use when considering escalating war in Afghanistan or bailouts to banks.

In a recent article for Tikkun, Dr. Arnold Relman argues that there is no way to meet that criterion unless health care reform includes eliminating the profit motive from medicine, including licensing doctors so that they get a fixed salary each year rather than, as now, making profits from prescribing more tests, procedures and visits that increase their incomes. He writes:

There are two interrelated critical issues in health reform right now: how to extend and improve insurance coverage, and how to control the unsustainable rise in health care expenditures. Virtually all of the current legislative attention is focused on the first issue but, notwithstanding claims to the contrary, none of the proposals now on the table offers any credible solution for the control of rising costs. Without control of health cost inflation, the present system will not be viable much longer.

Expansion of coverage is of course a highly desirable goal, but it inevitably increases expenditures even beyond today’s exorbitant levels. President Obama has repeatedly said he would veto any health proposal that is not “budget neutral” over the next decade. The legislation now under consideration claims to meet that requirement through savings promised by the insurance, drug and hospital industries and through reductions in Medicare expenditures (excessive payments to private insurers for Medicare Advantage plans would be a major target), possibly supplemented by taxes on employment-based health plans for high income employees. However, critics question whether these measures would fully pay for the almost one trillion dollars of new costs for covering most of the uninsured over the next decade.

But the estimate of the costs of expanded coverage does not include the cost of the constant inflationary rise in all medical expenditures, lately about 6 – 8 percent per year. This would increase total health spending by roughly another two trillion dollars over the next decade. Administration policy-makers speak hopefully of savings to be generated in the long term by switching to electronic records, using more preventive measures, and applying the information gained from studies of comparative effectiveness. But skeptics might call this “faith-based” savings, because there is no solid evidence to support such hopes. The sobering fact remains that something more must be done soon to slow medical inflation or the entire health system will inevitably slide into bankruptcy. And yet none of the legislation currently being considered addresses that problem. Adding more benefits to the system, and covering more people with public and private insurance, are certainly important, but even if those improvements were paid for, they would not slow down the numerous inflationary forces that make our medical care system unsustainable.

To read the rest of the article, visit Tikkun magazine’s Current Thinking section.

Arnold S. Relman, M.D. is a professor emeritus of medicine and of social medicine at Harvard Medical School, Boston, Massachusetts. He is a former editor of the New England Journal of Medicine (1977-91). His article is important because he explains why the reform that is needed must go beyond “public option” so that it can eliminate the constant growth of medical costs. This is a perfect example of what we at Tikkun and the Network of Spiritual Progressives call “New Bottom Line” thinking. Please ask your medical practitioners if they would agree with this article — and send it to all your friends.