The $750 billion Americans will spend on health care this year - and the trillion dollars in 1994 - should be an opportunity to release the poor from rationing and give all Americans all the health and long-term care they need.

Instead, to stem rocketing costs, Richard Darman, director of the Office of Management and Budget, some legislators and the General Accounting Office suggest rationing health care for all of us.No politician or bureaucrat has the wisdom to decide who should suffer how much pain for how long, who should walk and who should limp, who will live and who will die - and when.

Here are some ways to free up resources to provide all Americans with the care they need for what we are now spending, or less.

- Revamp the medical malpractice system.

The Bush administration is right to use federal programs to prod state malpractice reform.

We should develop standards of care to establish under what circumstances which medical procedures work.

Any doctor who follows those standards should have a defense to any charge of malpractice.

Where providers are negligent, states should limit recovery for pain and suffering and sharply reduce contingent legal fees.

- Relax the doctors' monopoly over the practice of medicine.

Once essential to protect patients from quacks and charlatans, the doctors' monopoly is now an economic hammerlock that keeps costs high and denies us the savings and efficiencies of modern technology.

Today trained nurses can perform all sorts diagnoses and treatments of common ailments, such as respiratory diseases, sprains and breaks, just as competently and far less expensively than doctors.

Midwives can handle normal deliveries.

These physician assistants earn less than half the income of doctors.

- Require that insurers and managed-care plans compete on the basis of service and price, not on the basis of who can attract the most low-cost patients.

Now most insurers and managed-care plans vie for the healthiest beneficiaries.

If all plans were community-based - with rates determined by the needs of the entire community - and were required to cover anyone who could pay, they would be forced to compete on the basis of price, service and efficiency.

- Medicare, Medicaid and private insurers should refuse to reimburse (or at least reduce payments to) hospitals operating at less than 60 percent capacity.

We've got to eliminate the inexcusable level of excess capacity in our hospitals.

Residents of towns with hospitals where doctors and nurses don't perform operations enough to maintain proficiency, much less attain excellence, would be better off investing in a first-class primary care clinic and a helicopter.

Insurers would save money by paying for such transportation rather than to keep the hospital open.

- Change the way we pay doctors.

It's time to pay doctors to talk with us, not just to do something to us.

Fees for such consultation are better spent, particularly when physicians are talking about health promotion and lifestyle changes.

It's also time to pay family practitioners more and some specialists less.

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Medicare is moving in this direction; private insurers should follow.

Before politicians and bureaucrats resort to rationing for everyone, they should stop tinkering and make fundamental changes in the way we deliver care.

Then we can provide high-quality care to all - rather than a declining quality of care to some.

(Joseph A. Califano Jr., a lawyer, was secretary of health, education and welfare from 1977 to 1979.)

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