Harry and Louise: the sequel.

Remember Harry and Louise? They were the earnest yuppie couple featured in TV ads sponsored by the insurance industry who tirelessly reminded us of the loss of options we would face if the government started to play a larger role in health care. Well, Harry and Louise were right, sort of. Health-care reform was defeated, and most citizens are rapidly losing their options in health care. The villain, however, is not those pernicious government bureaucrats. It seems that Harry and Louise's celebrated private health-insurance corporations are just as capable of burying us ever more deeply in a bureaucratic maze.

All over the country, physicians are joining various managed-care and HMO networks. Are medical consumers suddenly demanding this kind of health care? No. The powerful players in these changes are the large insurance and health-delivery corporations, which pretend to be so solicitous about our health-care choices. They have enormous financial muscle and have been making deals with doctors to get them to join networks. And major employers, in an effort to cut costs, increasingly force workers to accept these providers. Republican efforts to "save" Medicare may push many senior citizens into the same managed-care plans.

Even physicians themselves can do little to stem this tide. Once a substantial number of patients are in such programs, most physicians must join to be assured of enough patients to cover their overhead. Our health care is increasingly controlled not by our individual purchasing decisions but by corporate employers and corporate health-delivery systems.

Should we be concerned? Evidence suggests that some of these corporate health providers care more about their profit margins than about our health. Expensive but necessary care is too often denied, hospital stays dangerously shortened, nursing staffs increasingly overburdened, labs forced to read too many tests in too short a time. In Milwaukee, Wisconsin, last year the district attorney obtained a conviction of a lab for wrongful death in a case where pap smears were misread, in part because technicians were forced to read smears at four times the usual rate. Look for more such cases in an era in which corporations manage medicine with an interest in the bottom line.

But free-market advocates reply: won't competition put inadequate health providers out of business? Possibly, but keep in mind that even the most ardent defenders of markets talk about the "long run" benefits of competition. And as John Maynard Keynes once quipped, "In the long run, we're all dead." Advocates of the competitive model also forget that in many parts of the country effective competition among health-care providers is no more than an academic's fantasy. Many rural areas--including most of my home state of Maine--will never see substantial competition in our lifetimes.

Market advocates also forget that competition can often produce increasing market concentration. Once markets are dominated by two or three players, competition in practice amounts to little more than differing advertising images and logos: Reebok versus Nike.

If this world of medical oligopolies offers no real choice or competition, its efficiencies and savings may also be illusory. Steffi Woolhandler and David Himmelstein, Boston-based family physicians who have studied health economics, point out that economies of scale in HMOs are generally non-existent once one gets over 100,000 patients. Consolidation is based upon pecuniary strength, advertising advantages, and other monopolistic barriers to entry. Unlike certain mass-production industries, bigger isn't generally better or more efficient in this business. Bigger can mean more bueaucratic and more insulated from the needs and complaints of the typical patient.

I understand my conservative friends' complaints about government bureaucracies. Some are unwieldy, insulated from public input or even the advice of their own staff. What I cannot understand is how they fail to recognize that many of these same characteristics are present in the private sector and are often even intensified by current market trends. I don't know about you, but I'd rather deal with the Social Security Administration than with most of the private insurance bureaucracies with which I have had claims or problems.

The tragedy of the Clinton health-care fiasco becomes more clear every day. The failure of the administration to present a clear and comprehensible alternative that effectively addressed the deleterious role of the insurance conglomerates was a grave error in judgment or courage. The common wisdom today is that this failure doomed health-care reform for at least another generation. The very complexity of the Clinton scheme only confirmed American's fears about government and resistance to taxation on its behalf.

Yet the ranks of the uninsured grow along with personal insecurity about health care. Even those workers fortunate enough to receive full health care through their employers realize they are paying for this care with diminished wages and are subsidizing the uninsured indirectly through emergency room costs passed along to the rest of us. Courageous political leaders or grassroots activists could again put this issue on the agenda.

Health-care reform would have an easier time if it started with three simple premises:

* A genuinely universal system ought to be financed through the income tax, the fairest and broadest of our taxes.

* Cost containment in the area of health care cannot be delivered simply by markets.

* Efficient and defensible regulation is facilitated by giving states and consumers more voice in the system.

We need a single-payer system that writes the expensive and inefficient insurance middleman out of the system. Government could set basic budgets for both hospitals and physicians, negotiated with all major players. It could then make grants to states whose hospitals and physicians would manage health care on a day-to-day basis within these budgets. States might then be allowed to experiment with such options as nonprofit HMO-style practices managed by provider and patient boards. States could thus develop both better methods to assess traditional fee-for-service care as well as innovative, consumer-driven alternatives to it.

Even the older, more traditional modes of health care need reform. We shouldn't romanticize the style of health-care delivery lovingly portrayed in such TV series as "Marcus Welby, M.D." That system placed severe burdens on individual providers and often made them autocrats in their own right. But corporate bureaucracies are no answer to these problems. The only humane and efficient way to improve health-care quality within an affordable budget is to give consumers more knowledge of health-care issues and more voice in the system.

As it is, corporate interests are remaking health care in ways which give consumers and citizens little more than marginal input. Short of more fundamental reforms, at the very least HMO members must have a bill of rights that would guarantee patient representation on HMO boards, better quality audits, more accessible information, and limitations on each HMO's financial reach. But I wonder if Harry and Louise would once again protest such reforms as more governmental incursions into our sacred free-market choices?