The debate over health-care reform has sparked all sorts of controversy over costs, regulations and choices. But one "feature" seems to have escaped notice: the built-in lack of accountability of our elected leaders for what health care will be like after the plan is implemented.

Proponents claim we need reform now to solve an immediate health care "crisis." "If we don't act, 14,000 Americans will continue to lose their health insurance every single day," President Obama claimed on July 22.

Yet the bills he urges us to support will not actually provide any health care until 2013 _ by which time, if the president's claim is correct, an additional 17 million Americans will have lost their insurance.

Why the delay? The best way the people have to hold their elected leaders accountable for results is by threatening to withhold their votes. But this bill seems expressly designed to eliminate that source of accountability. By the time Americans experience the effects of this health care bill (except for the tax increases), not only will President Obama have run for re-election, but so will two-thirds of the senators _ and every House member will have been up for re-election twice. Their votes on health care reform will be old news. If it goes very badly, it will be too late to vote those responsible out of office.

Furthermore, the House bill leaves all the knotty details and controversial issues to the newly created "Health Choices Commissioner." That's the person whose job it will be to make a lot of our health care choices for us. The Senate Finance Committee (Baucus) proposal gives that authority to the secretary of Health and Human Services. Issues such as whether to:

_Permit people with Health Savings Accounts (HSAs) to retain the high-deductible health plans required by the HSA law.

_Allow low-cost catastrophic plans.

_Permit insurance companies to cover treatment of otherwise terminally-ill patients.

_Require (or prohibit) coverage of abortion.

_Cover new cancer drugs or controversial procedures like (as the Center for American Progress has called for) "transgender" operations.

These and other issues will be left to an appointed official. Elected leaders will never have to face the voters and defend these crucial decisions that affect the life and health of every American, since the decisions will be made by an unelected bureaucrat.

Any representative or senator confronted by an angry constituent could respond, in effect, "I didn't say grandma couldn't have a pacemaker. I didn't deny you that expensive cancer drug. It was the independent, nonpartisan Health Choices Commissioner. Congress _ let alone any individual member _ can't micromanage every decision the commissioner makes."

By pushing the tough decisions onto a bureaucrat _ so they don't have to go on the record by voting _ they effectively enact a system that allows them to dodge accountability.

The same official would also have the authority _ even the duty _ to audit the private plans that complete with the public option (or "co-op"), both employer-sponsored plans and plans sold by insurance companies. The official could audit plans randomly or "in response to complaints" _ and according to the House bill, demand "reimbursement" for the cost of the audits. In effect, a competitor or disgruntled former employee could run any employer or insurance company out of business by filing repeated complaints to force the targeted company to pay the cost of repeated audits to verify their manifest innocence.

And if the commissioner determines that any violations have occurred? Then according to the House bill, he or she is authorized to impose civil money penalties, suspend further enrollment in the plan, withhold premium payments made through the federal "exchange" and "work with State insurance regulators to terminate plans" (p. 45).

These penalties are entirely up to the commissioner. No particular evidentiary standard is required, and no appeals process is specified or mentioned, let alone any decision by a judge or jury. The commissioner, who will administer the "public option" or "co-op" plan, is totally unaccountable to anyone for penalties imposed on competing private health plans. And does anyone expect him or her to impose penalties on the "public option" or "co-op"? Is this the promised "level playing field"? The one designed to "keep insurance companies honest"?

The real question is, with such broad and unaccountable authority, who will keep the Health Choices Commissioner and the secretary of Health and Human Services honest? And more important, with none of this taking effect until after the next two elections, who will keep the politicians honest?

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ABOUT THE WRITER

Robert A. Book is senior research fellow in health economics at The Heritage Foundation. Readers may write to the author in care of The Heritage Foundation, 214 Massachusetts Avenue NE, Washington, D.C. 20002; Web site: www.heritage.org. Information about Heritage's funding may be found at http://www.heritage.org/about/reports.cfm.

This essay is available to McClatchy-Tribune News Service subscribers. McClatchy-Tribune did not subsidize the writing of this column; the opinions are those of the writer and do not necessarily represent the views of McClatchy-Tribune or its editors.