Tyler Taylor, who directs Care First LLC in Los Alamos, has been a family physician in small towns for more than 30 years and has practiced in Los Alamos since 2000. Frustrated with a health care system that has been, in his words, "getting more profit-driven, irrational and unethical," he has been speaking out in public at forums and rallies for the first time in his life. He has been encouraged by his belief that, "in New Mexico, progressive ideas get a fairer hearing than in much of the U.S." Asked if universal health insurance is a "right," he replies, "I'm not sure about that, but I know it's the right thing to do."

Michael Lehrer: According to a recent random survey of over 2000 physicians funded by the Robert Wood Johnson Foundation, 62.9 percent of the doctors support a "public option" being offered in addition to private insurance plans, and a majority support a widening of Medicare eligibility. The Mayo Clinic, however, contends Medicare "has not controlled costs and has punished doctors, hospitals and others that provide high-quality, affordable care." How do you see it?

Taylor: Doctors, by and large, want everyone in the U.S. to have good, basic health care. They want an elimination of much of the bureaucratic waste and aggravating hurdles in the system, a much less punitive system for dealing with patient care errors, some of which are inevitable, and to re-establish the old social contract between doctors and patients with much less "outside interference."

I remember when Medicare was very reasonable health care coverage to have in the 1980s. As health care costs on all fronts went rapidly up, and government/taxes became "the problem" to many Americans, Medicare slowly became second-class coverage. This means the government has reneged on its commitments to the patients and providers. Republicans have never been enthused about Medicare, and have kept it from thriving.

Also, both Medicare and private insurers have kept using the old paradigm, giving incentives to providers to do more care, and not the best care. What the Mayo leadership seems to be calling for is a rebuilding of our health care system based on the right priorities and smart ideas for incentivizing providers to deliver care that is more ethical, better coordinated, more patient focused, better planned and produces better outcomes. All of the payers, including Medicare, should be moving steadily in that direction. This would be the biggest reform of all, and is still years away.

Lehrer: In a recent Kaiser Family Foundation poll, 37 percent of seniors feel that health care reform will result in a lessening of care for them. Is this fear justified?

Taylor: For those people with Medicare Advantage plans, the substantial cut in federal subsidies to the companies that sell those highly profitable plans will affect their viability. These companies will get out of some U.S. markets, and will probably use more deception of customers in others. So patients with those higher-cost plans will see a difference. Nonetheless, they will still have standard Medicare coverage, and will still be able to get supplemental coverage from many companies (covering the 20 percent of the "allowable cost" Medicare does not cover). But many who have been getting Advantage plans will have to pay out of pocket for a few of the more optional items.

There are also two very positive parts of health care reform for seniors. The biggest is the federal government preventing a 21 percent cut in Medicare payments to providers. Without this emergency action, these massive cuts will occur on Jan. 1, 2010, and many more doctors will stop taking Medicare patients. It's also highly likely that a final reform plan will expand the preventative services that Medicare offers, such as physicals, tetanus shots, etc. Right now there are about a dozen common preventative services that Medicare doesn't cover, and it severely underpays for mental-health services. So questioning all the basic assumptions regarding health care coverage, including Medicare, will lead I believe to better plans in the future

Lehrer: Do you think that linking physician and hospital reimbursements to outcomes and patient satisfaction is integral to health care reform? Can it be done fairly?

Taylor: These concepts are not integral to health care reform at this stage, but are extremely valuable for consideration in the next three years. The Mayo leadership has good ideas about how much weight to give, in determining physicians' incomes, to patient safety issues, good treatment outcomes and patient satisfaction with services. I believe that it's very possible to do this fairly, and suspect that strong models will arise as the emphasis shifts away from "doing more." It's important not to go to the extreme that HMOs were using in the 1990s, highly rewarding doctors for withholding care.

Our current health care nonsystem is loaded with semi-rational carrots and sticks for providers, and they get changed often, in Byzantine or devious ways. It is liberating to imagine a system focused on outcomes instead of work volumes; that rewards giving the optimum care needed, but not more or less.

Lehrer: You grew up in Alabama and have compared the current health reform efforts to the civil rights movement. Could you reflect on this?

Taylor: I think there are many parallels between our current health care situation and the civil rights movement of the 1950s-1970s. The fear of health care change among the "haves" and the powerful is intense, and is leading people to say the kind of outrageous things that once passed for truth among southern whites. The willingness to ignore the uninsured, those going bankrupt and those dying for lack of health care feels familiar. There's been the same tendency of those comfortable with what they have to believe that they deserve what they have, and the poor don't deserve it. This time they argue economics and social theory instead of "God's plan" and states rights, but the intense fear of egalitarianism, of justice for the poor is still the same. Reforming the U.S. health care system can not be done in one giant leap. Each future reform will probably build on the foundation of 2009 changes. To dramatically improve U.S. health care, the powerful will have to be slowly exposed, marginalized and replaced with the next, more forward-looking generation. And I believe that will take one to two decades, as did achieving integration and the equality of civil rights from the 1940s to the 1970s.

Michael Lehrer is a former Los Angeles teacher and a writer who now lives in Santa Fe. He became acquainted with Taylor at a rally earlier this year in Albuquerque to show support for the public option. The interview is a result of e-mails and conversations between Lehrer and Taylor.