– Stephen M. Davidson, a Boston University School of Management professor, is author of the forthcoming book, “In Urgent Need of Reform: The U. S. Health Care System” and blogs about healthcare topics on Huffington Post. The opinions expressed are his own. –

Now that the Republicans have ended the pretense and revealed themselves to be unwilling to compromise to produce a bipartisan healthcare reform bill, they have freed the president and Congressional Democrats to return to the drawing board and get it right.

As a first step, they should articulate a vision of what a good healthcare system should look like and an understanding of why our present system does not meet that standard. Then, reforms can be offered that will overcome the obstacles and get us close to that vision. Here is a start in that direction.

Following reform, we want everyone to have access to the care they need to keep them healthy, return them to health when necessary, and help them manage their chronic conditions. We want access to good primary care to be a reality for everyone. We want sufficient services to be available so that everyone can avail themselves of the ones they need. And we want them to be of reliably good quality.

We want to avoid any system features that discourage people from seeking appropriate care from the most appropriate source at the most appropriate time. And we want to avoid other system characteristics that encourage providers to reject some patients or that discourage them from providing the care they believe their patients really need.

Finally, we want patients to get services they need, but not ones they don’t need; and we want providers to be efficient in delivering those services so that money is not wasted.

We want all these things not only because individuals will benefit, but also because a healthy populace is good for the society and the economy. Moreover, without the stability and predictability these achievements imply, the service delivery subsystem will deteriorate further and become increasingly unreliable.

Unfortunately, the reform proposals being discussed in the Congress are unlikely to take us to this end state. Instead, to get there we need all of the following key provisions:

• Everyone must have comprehensive health insurance. Indeed, there is no good justification for any other outcome.

• Further, universal coverage is the single most important step needed to arrest the deterioration of the healthcare delivery subsystem. Providers will be able to count on a reliable source of income no matter where they locate and, therefore, to open offices anywhere that does not have enough providers to meet residents’ needs.

• Everyone needs access to a personal primary care physician and, through him or her, early access to needed care.

• All needed services must be covered; and providers should know that, if they exercise their best clinical judgment, they will be reasonably compensated for their work.

• To improve quality, opportunities must be maximized to take advantage of information technology and to build teams and coordinated care; and system-generated obstacles to good quality care must be eliminated.

• Costs – from insurance premiums and utilization, including patients’ out-of-pocket costs – must be kept under control. High out-of-pocket costs discourage individuals from seeking needed care. And high total expenditures will force insurers to cut back covered services and will make insurance too expensive for many to afford.

In looking for solutions, the first thing to notice is that the problems – high and rising costs, many Americans without insurance, and unreliable quality of care – are the aggregate result of millions of separate decisions made by individuals acting either for their own benefit (for example, as patients or doctors) or as representatives of various groups or organizations. Moreover, while we usually think of uninsurance and runaway expenditures as the problems, they are really results of other causes. Therefore, to change the outcomes, we need to identify and overcome the underlying causes so that people will make different choices.

So, why do people make dysfunctional decisions? The main answer is cost. To cover the cost of services used by their subscribers, insurers raise premiums, among other things. In turn, faced with high insurance costs, employers drop coverage altogether or reduce their own costs by increasing employees’ share of premiums and out-of-pocket costs of care, and drop family members from coverage. Many employees, in turn, react to higher premiums by rejecting the insurance offered to them and, even if they do buy it, don’t use needed services because out-of-pocket costs are too high. And providers raise their fees to cover their own increased costs incurred to cope with the huge variety of insurance provisions and to pay for innovations, like information technology.

The aggregation of all the independent decisions — to buy or not buy insurance, or to use or not use services — has created the problems that need to be solved. Democrats should appreciate the gift Senator Enzi and other Republicans have provided. Relatively simple solutions are available at modest cost if we are serious about solving the problems and no longer need to placate reluctant Republicans. They should roll up their sleeves and get to work.