To Pay the Bill, Break Down the Pill : Health care: Nationwide reform is too big to swallow. Instead, try vouchers while seeing what works in states.

We admire Bill and Hillary Clinton and deplore the rising chorus of naysayers calling for their heads because they have failed to perfect America in their first six months. Still, the First Couple’s centerpiece, health-care reform, could very well become their Waterloo. As it almost became ours.

One of us, the doctor of medicine, argued that the Clintons’ policy wonks, however well-meaning, would inevitably destroy what remains of the delicate bond between doctor and patient, while the other of us, the doctor of philosophy, having spent decades diagnosing systems and redesigning organizations, argued that chaos always precedes order. After several noisy and combative innings, it became clear that we had better find some common ground, or we would soon be dining at separate tables.

There’s no question that the health-care system is in urgent need of redesign for its own sake and the sake of the nation. It’s a $1-trillion slice of the $6-trillion American pie. The well-being of each of us--physical, emotional and financial--is dependent on the system’s well-being. When it’s in trouble, we’re all in trouble.

The good news is that the practice of medicine in America in the 1990s is as close to perfect as it is likely to get. The bad news is that the management and delivery of health-care services is about as bad as it can be--costly, complicated, confusing and often heartless.

The foundation of any health-care system is the relationship between physician and patient. One doctor, one patient, one at a time. In the crude and inexact language of our era, the patient is the consumer and the doctor is the provider. Or should be. But, in recent years, both doctors and patients have been relegated to minor supporting roles. The insurance companies are the stars now, playing both consumers’ and providers’ roles.

That’s why the first question put to a patient today is not “Where does it hurt?” but “What’s your insurance company?”

Any effort to reform our health-care system must begin by recognizing the primacy of the doctor-patient relationship and restoring it. Since that relationship is the crux of the matter, and since it is, like all relationships, personal, intimate and instinctive to some degree, patients’ freedom of choice must be reaffirmed, too. The simplest and most direct way to achieve both of these necessities is a voucher system, modeled along the lines of the superbly simple G.I. Bill. Under this system, vouchers would be issued directly, in quantities based on doctor-visit averages for each individual’s age group. This voucher system would not only eliminate the middlemen, it would reduce patient and system costs and much paperwork.

That, in a nutshell, is what we would do if were the First Couple, with the proviso that knowing what to do is far easier than figuring how to do it.

Every one of us, every organization and every institute in the nation will be affected, for better or worse, by what is done, and so whatever is done must be done with great care. And that will take a lot more than a few months.

Further, in any task of this heft and loft, mistakes are inevitable, but, more often than not, instructive. President Franklin D. Roosevelt, one of this country’s most masterful agents of change, recommended “Bold, persistent experimentation. It is common sense to take a method and try it; if it fails, admit it frankly and try another. But, above all, try something.”

Rather than struggling to forge one immense monolithic program now, Hillary Rodham Clinton’s task force should instead forge partnerships with the states and work with them on pilot programs. Right now, New York, Washington, Oregon and Florida are responding to their own particular health-care crises with creative alternatives. The task force should work with them and encourage other states to develop innovative means of solving their own health-care problems. With 50 diverse and heterogeneous states as laboratories, the task force could test many possible approaches simultaneously, refine promising ones and abandon unworkable ones at little cost. And, out of all this experimentation, a workable health-care system will finally emerge.

The President has often spoken of fashioning a federal-state partnership. It’s time for him to walk his talk.