The controversy about HMO practices, as evidenced by the current dispute about the differing proposals for a "Patient Bill of Rights," shows something of the confusion that our society is experiencing over what it wants and expects of our health care system.

One of the advantages of age is looking back and seeing how a previous decade’s solutions become this decade’s problems. When I was about 19, I was self-employed, and I had no health insurance. Like a number of the uninsured today, it wasn’t because I couldn’t afford it – I just didn’t see that I needed it particularly. So when I first started to see press coverage of the health care problems of the 1970s, I followed the subject with more concern than many of my insured peers. While there were pundits complaining about a shortage of health insurance back then, the bigger concerns were the cost of medical insurance, and the unnecessary procedures that doctors were performing.

The two problems were doubtless connected. If, as many critics claimed, doctors were performing unnecessary hysterectomies and C-sections to fatten their paychecks and ordering too many tests "just to be sure," I guess we shouldn’t be surprised to find that this added to the medical bills – and the insurance premiums – for governments, employers, and uninsured people like myself. While I don’t doubt that there were doctors driven by greed, health care critics of that era seldom acknowledged the other motivations: doctors who looked only at curing their patients, regardless of the cost, and doctors who ordered extra tests as a defense against negligence lawsuits.

Insurance companies responded to the complaints about rapidly rising premiums – and especially to the increasingly strident threat of national health insurance – by increasingly effective cost-containment policies. The current complaint about HMOs is that accountants, not doctors, are now calling the shots on what to do, and when. But isn’t it interesting that we no longer hear so many complaints about unnecessary C-sections and hysterectomies? Perhaps the pendulum has swung too far from the 1970s, when the only time a doctor thought about the cost of a procedure was when he knew his patient was uninsured. A physician expressed his concern about this to me some years ago, "You send a patient to see a cardiologist about a heart murmur, and the next time you see him, he’s got a huge scar on his chest." Before we engage in an orgy of recriminations at the insurance companies for being stingy and putting profits over patients, let’s remember that part of what motivated their current pennypinching strategy was complaints about overly aggressive and overly expensive medical care.

Medical care is expensive. The very best medical care is very expensive. If we complain about the costs of medical care, we shouldn’t be surprised if insurers decide to take us at our word, and rein in the doctors who are trying to give us all the medical care that we want.

Clayton E. Cramer’s fifth book, Concealed Weapon Laws of the Early Republic: Dueling, Southern Violence, and Moral Reform will be published by Praeger Press this year.