Americans want the best. Best house, car, children's education, vacation destination, kitchenware. And, of course, best health care.
Understandable ambitions, all. Especially the intangibles of education and health.
For the most part Americans also want bargain health care costs. And that's the root of the heated congressional debate over HMOs.
Best and bargains have come to define the opposite extremes of America's managed care debate - its quality, as one end of a pendulum swing, and its costs as the other.
Maximizing both, Americans and their lawmakers keep rediscovering, causes medical rationing.
Over little more than three generations, the average citizen in US society has travelled from a world in which individuals largely looked out for their own health, often in direct relationships with doctors or other practitioners, to one in which employers, insurers, and federal or state government helped fund and manage group relationships.
Of course funding by an employer, insurer, or government is a misnomer. Employees, customers, and taxpayers have to fund those institutions' plans.
And, of course, group relationships are merely a bundling of individual relationships between the intended curer and curee. That's why the current outcry over HMO's rationing of specific treatments is occurring. Individuals complain when they can't get what they see as the best, just as they complained previously when costs rose too rapidly.
In the past quarter century, first business, then government discovered that the meteoric rise in health care costs was becoming financially insupportable. Businesses complained medical costs were making their products uncompetitive. Lawmakers discovered that Medicare and Medicaid were heading toward bankruptcy. The government-funded systems, like employer-funded plans, began to nudge citizens toward group managed care.
It's ironic that today Democrats and many Republicans are attacking managed care for bureaucratic callousness toward patients. Democrats should be glad they aren't having to defend the much more bureaucratic managed care system Hillary Clinton and Ira Magaziner proposeed in 1993. It would almost certainly have produced more horror stories than those told at current hearings.
Republican lawmakers should be fully backing a compromise that preserves the cost-cutting efficiencies of HMOs with an appeals mechanism for patients who claim quality care was vetoed by insurer-driven gatekeepers.
Such a compromise would avert some Democrats' demand that patients be able to sue immediately upon suspecting they have been denied best-quality care. That could send the US back to the ballooning costs that threatened national growth and undermined health care in the 1980s. Better to require an HMO appeals system that deals with grievances before thousands of people go to court.
Better still to get more Americans to lead balanced, healthy lives. That requires disciplined individual thought and effort, but pays off on both the quality and cost fronts.
The founder of this newspaper, Mary Baker Eddy, took as a fundamental premise of her outlook that "health is normal and disease is abnormal." That, lawmakers might note, is what the aim of managed care should be: to maximize the normal without contorted bureaucracy in this nation dedicated to life, liberty, and the pursuit of happiness.