1.Cover everyone. For too long we have had a health care system that that was like Swiss cheese full of holes. 47 million Americans are uninsured and millions more have such minimal health care that it is barely better than nothing at all. It is a matter of our humanity and a matter of economics that we repair the health care safety net. This is the year we provide health care to all.

2.Everyone Must Sign Up. Along with the benefits of a truly national health care system comes responsibility. Every American should be required to enroll in health insurance. Even the young and healthy will have to be part of the pool of covered people. The reason is simple in order for the plan to sustain itself at a reasonable costs, we cant have folks buying in only when they have health care needs. We are all in this together.

3.If you are happy with your health care you can keep it. We need to grow the coalition of citizens who want to solve the problem of the uninsured. To start with we should make sure that all Americans who have health insurance that they are happy with, are able to stick with what they know. On the other side of the coin, any new federal plan should carry a requirement that private insurers dont reduce coverage or dump customers when the new federal plans take hold. We need to ensure better care not a race to the bottom.

4.Preserve Choice. Competition works. More importantly, each citizen has individual health care needs. For both reasons we need to ensure that all Americans have an array of options when shopping for health care. Members of Congress and all federal employees have a big book of different plans with an array of options and price points. Everyone should have that range of choices.

5.Make sure Coverage is Portable. Too often people lose their insurance when they leave a job or move to a different city. This has to change. Its bad for our economy and it has a distorting influence on the decisions families make. Health care coverage should follow you wherever you go.

6.Strengthen Medicaid. Under any universal plan, we must make sure to have protections to ensure that the less well off among us still get quality care. Medicaid the Federal and State program for the lowest income Americans - varies from state to state. New York for example has a very expansive (and expensive) program. We need to make sure that the advances that health care has made in some states are protected.

7.Keep Costs Down. We all pay in one way or another for the high cost of health care. Some of us pay high premiums or co payments. Others pay too much for American made products because the cost of health care is built in. And all of us pay higher taxes for the treatment of the uninsured who get uncompensated care at our neighborhood emergency room. When we get everyone covered we need to take that large pool of citizens and demand lower costs. We didnt use this market power when we created the Medicare prescription drug plan and we paid the price literally.

8.Treat Illness but Preserve Wellness. The basic math of health care is that an ounce of prevention is worth a pound of cure. If we can keep people out of hospitals and doctors offices by getting them off cigarettes and into the gym, everybody wins. Simple things like ensuring access to good diets and diagnostics like mammography and colon screenings help to prevent serious illness and catch small problems before they become big ones. We can also save a lot of money by doing the humane thing by incentivizing treatment and care at home and not in a hospital or nursing home.

9.Fix the Gaps in Medicare. When everyone is covered, seniors who rely on Medicare will benefit from the downward pressure on health care costs. But there are some elements of Medicare that cry out for reform. The donut hole in coverage for drugs comes to mind. As our society ages, our program for the silver years should adapt and cover things like home care.

10. Maintain High Standards for Care. With millions of more Americans getting coverage, we need to make sure that we have quality care that begins with the teaching and training of primary care doctors and nurses. New York is the teaching hospital capital of the world. As with all professions, education is the foundation of a strong medical infrastructure. Let us create incentives for new nurses and doctors who go into primary care.

The main problem with our current health care system is that it requires payments.

I was listening to Thom Hartmann - an Air America radio guy - who had been visiting Germany on business. He felt ill one night. He approached the hotel desk and inquired about where he could find medical care. As it was after midnight he was directed to the local hospital. He went, filled out some forms, saw 2 doctors, saw a pharmacist, received a prescription medicine, and (since he was a tourist) was expecting a bill. There was no bill; not even for non-residents. Simple.

That's right: top flight medical care. Correct diagnosis of his ailment and the prescribed medicine provided the relief necessary. Germany offers such care at about 2/3s of US costs - Japan offers similar care for 1/3 US costs. Both have longer life expectancy rates than does the US.

Americans will complain they don't want higher taxes but I'll argue that health care premia, in fact, ARE taxes and are too high. Our health care needs can be met with less money than is currently being spent by our citizens.

Americans don't want to give up their freedom. A friend of mine pays $500 per month to cover himself. His doctor told him he needed an MRI. The insurance company said: "We'll see." After they investigated for four weeks, they gave him approval for his MRI. That's freedom? A bunch of clerks at the insurer deciding and delaying life and death medical issues. The US governemnt can come to the same conclusion for a fraction of the cost.

Do we have to cover foreigners visiting on their vacations? I don't know. Universal, single-payer coverage is the ONLY way to go.

I am a physician and I support for a national single payer healthcare system similar to the system currently in Canada. The reasons for this are threefold; first, the provision of universal health care seems to mean to be a moral imperative. I believe fundamentally that health care is a right (like a basic education), not a privilege and I believe that a single payer system is the plan mostly likely to get us to universal coverage. Secondly, I am convinced that the free market economy does not work to control costs. Thirdly, the free market does not work to provide the highest quality healthcare to our citizens; the incentives are all wrong.

Let me first disclose my background in order to be clear about my own biases. I am a physician, and Associate Professor of Psychiatry. I am proud to note that my primary appointment is as a physician at the James J. Peters VA Medical Center in the Bronx, New York.

On the first point of concern, universal health care in our current system is simply impossible. The private insurance companies want to provide insurance to those who are fundamentally healthy. To care for those with serious chronic illnesses simply costs too much for them to make money. Therefore, in our current system, the cost of chronic illness is borne by Medicare and Medicaid. The private sector gleans profit from insuring those who have no major need. Once people are old (and therefore more likely to develop serious chronic illnesses), have a serious disabling chronic illness (and therefore fall into Medicare-Disability) or are so poor that they cannot work (likely to be at risk to be ill because of social problems such as substance abuse, poverty, malnutrition, or poor because of a mental illness that interferes with their ability to work), people fall into the government funded programs. I have heard it argued that the last thing we need is government run healthcare, in light of the financial disasters of Medicare and Medicaid. This misses the point. Private companies insuring only these high risk populations would be rapidly run into the ground as well.

The second point is that the free market doesnt work for health care. Buyers of health care are not the consumers, but rather the employers most commonly. The usual free market system, which permits the consumer to purchase the best and most cost effective product, and to refrain from buying products with which they are dissatisfied, simply does not work for healthcare. The consumer often has no choice of insurance provider. Furthermore, even if the consumer can chose, a consumer who has yet to experience serious illness may well not know how to evaluate a health program. Once he/she has a serious illness and learns about the adequacy of his/her coverage, it is often too late to change. He/she now has a prohibitive preexisting condition.

Thirdly, the current fragmented health system has the incentives which are completely out of line with public health needs. The reimbursement incentives for how to practice medicine and the training of doctors are not public health oriented, but rather focus exclusively on caring for the individual. The training example is easier to fix. I recall that when I was resident, I raised concerns about whether a test was the right thing to do for a patient. It seemed to me to be a low yield, costly and physically painful test for the patient. My supervisory attending told me to keep my mouth shut If you think of a test, you need to do it, as if my reluctance was related to laziness, not concern about whether it was best to do the test. This is an example of a training problem. I am currently involved in developing and modifying the curriculum at Mount Sinai and I do think that many medical schools are, like ours, changing this culture.

The inappropriate financial incentives pose a more difficult problem to solve. It is often in the financial interest of a hospital to do more: more tests, more procedures etc. For each test and procedure, doctors and hospitals are paid more. The DRGs (or diagnosis based reimbursements) were an attempt to mitigate this incentive, but have really not worked to contain costs. Instead they penalized tertiary care hospitals that took responsibility for the sickest and most complicated patients. It remains a fundamental problem that the doctors whose work involves primarily interventions and procedures, (such as radiologists and surgeons) are reimbursed for their services at an exponentially higher rate than doctors who spend time talking to patients and using their wide body of knowledge to come up with a proper diagnosis and a plan. This would include internists, pediatricians, family medicine doctors, psychiatrists. This same group of physicians typically takes responsibility for the care of patients with chronic serious illnesses. Finally, the interventions are often done to test for the rare disease (in medicine known as the zebras), whereas many of the major causes of poor public health are not even covered by most health insurances. The most recent data from the World Health Organization notes that of the top 10 illnesses contributing to disease burden in high-income countries, the greatest in unipolar depression, and an addition two of the ten are mental illnesses. When considering disease burden for women (ages 15-59) in high income countries, by far the largest contribution is from mental illness. Yet, the reimbursements from private insurers, from Medicaid and even from Medicare are so low that almost no psychiatrists I know accept insurance coverage. We need to be careful about this as we design a public system. We want intelligent young physicians to go into specialties like family practice and psychiatry. It should be noted that Canada is constantly recruiting American Trained psychiatrists. They recognize their need for more psychiatrists and frankly, Canadian psychiatrists earn more money than American psychiatrists.

The Veterans Affairs Medical Service provides a clear counterexample to the free market approach. We are given a budget to care for our veterans and we deliver cost effective healthcare based on what the veterans need. A great proportion of that care is mental health care; this is only in part the result of the exposure to trauma and stress during their military service. It is also because mental illnesses are simply very common, and in fact among the most common chronic illnesses that afflict young people. It is also important to note that many of them are highly treatable, and when left untreated, they ruin peoples lives. We, in academic psychiatry, are at the forefront of evidence-based practice, and have come to hold field to extremely high standards of empirical scrutiny. The VA system is not perfect, but our single payer haven in US healthcare is one shining example in our country of system wide decisions to actually not only treat illness and to evaluate the effectiveness of our service delivery, but also take a measure of responsibility to rehabilitate our chronically ill patients with employment preparedness through compensated work therapy.

I felt obligated to raise these concerns as I have seen so much confusion in discussions by experts in healthcare. Statements such as a free market economy brought us a great phone system. Competition gives us the best productnot in healthcare. I recall listening to a member of the Clinton healthcare advisory discuss mental healthcare needs. He said that he believed that a certain low level of mental health coverage would meet the mental health needs of 90% of Americans. I asked if that 90% were those with no serious chronic mental illness, and he had no answer! I was a supporter of President Clinton and have worked arduously to elect President Obama and the Democratic Congress. I am thrilled with the election results. On healthcare, however, we can and need to do better.

In writing this, I recognize that a single payer system may not be politically feasible now. I do think, however, that an optional public plan would be helpful. Medicare and the Veterans Health systems have proven that government can run a good health system at lower cost than the private sector. This could drive costs down in terms of insurance premiums. It does not, however, solve the problem that private insurers select their patients by seeking to cover only those who are young and healthy. If the private sector is not forced to accept everyone, they may indeed be able to match the per-patient costs for health care of the public sector; however, they will be covering the least costly patients to provide for. It wont be a fair comparison.

1. Cover All Americans. For too long we have had a health care system that that is like Swiss cheese: full of holes. 47 million Americans are uninsured and millions more are underinsured and cannot access the health services they need. It is most importantly a matter of our humanity, but also a matter of economics, that we weave our current system into a true health care safety net. This is the year we provide health care to all.

2. Everyone Must Sign Up. Along with the benefits of a comprehensive national health care system comes responsibility. Every American should be required to enroll in health insurance so he or she can access health care when it is needed. Even the young and healthy will have to be part of the pool of covered people. The reason is simple: in order for the plan to sustain itself at a reasonable costs, we can't have folks buying in only when they have health care needs. This represents a paradigm shift that finds an analogy in cellular phone plans: no longer will some be able to have "pay-as-you-go" plans that often are inexpensive but occasionally result in catastrophic bills; instead, everyone must purchase a plan for a monthly fee to ensure that resources are accessible when they are needed. We are all in this together.

3.Retain Current Coverage (if you want). We need to grow the coalition of citizens who want to solve the problem of the un- and under-insured. To start with, we should make sure that all Americans who like the health insurance they have with are able to stick with what they know. On the other side of the coin, any new federal plan should carry a requirement that private insurers don't reduce coverage or dump customers when the new federal plans take hold. We need to incentivize striving for better care rather than encouraging a race to the bottom.

4.Preserve Choice. Competition works. More importantly, each citizen has individual health care needs. For both reasons we need to ensure that all Americans have an array of options when shopping for health care. Members of Congress and all federal employees have a big book of different plans with an array of options and price points. Everyone should have that range of choices.

5. Make Coverage Portable. Too often people lose their insurance when they leave a job or move to a different city. This has to change. It's bad for our economy because it leads to gaps in coverage and it has a distorting influence on the career and domestic decisions families make that should be independent of the effects on health insurance. Health care coverage should follow you wherever you go or wherever you work.

6. Strengthen Medicaid. Under any new plan, we must make sure that protections which ensure the less well-off among us get quality care are made stronger. The quality and extensiveness of Medicaid - the Federal and State program for the lowest income Americans - varies from state to state. New York for example has a very expansive (and expensive) program. We need to make sure that the advances that health care has made in some states are protected.

7. Keep Costs Down. We all pay in one way or another for the high cost of health care. Some of us pay high premiums or co-payments. Others pay too much for American-made products because the cost of health care is built in. And all of us pay higher taxes for the treatment of the uninsured who get uncompensated care at our neighborhood emergency room. When we get everyone covered we need to take that large pool of citizens and demand lower costs. We didnt use this market power when we created the Medicare prescription drug plan and we paid a high price for that choice.

8.Treat Illness and Promote Wellness. The basic math of health care is that an ounce of prevention is worth a pound of cure. If we can keep people out of hospitals and doctors offices by increasing health behaviors empirically-linked to wellness , everybody wins. Simple things, such as ensuring access to nutritional diets and diagnostics like mammography and colon screenings, help to prevent serious illness and catch small problems before they become big ones. We can also save a lot of money by doing the humane thing by incentivizing treatment and care at home and not in a hospital or nursing home.

9. Close Gaps in Medicare. When everyone is covered, seniors who rely on Medicare will benefit from the downward pressure on health care costs. But there are some elements of Medicare that cry out for reform, such as the "donut hole" in coverage for medications. As our society ages, our program for the silver years should adapt and cover things like home care.

10. Maintain High Standards for Care. With millions of more Americans getting coverage, we need to make sure that we have quality care that begins with the teaching and training of primary care doctors and nurses. New York is the teaching hospital capital of the world. As with all professions, education is the foundation of a strong medical infrastructure. Let us create incentives for new nurses and doctors who go into primary care.