Since major health care reform legislation died in Congress, the emphasis has been on "incremental reforms," such as the Kennedy-Kassebaum portability bill, the President's proposal to extend eligibility for Medicare, and a proposed Patients' Bill of Rights. Since 1993 the growth of health care costs in the U.S. has slowed, but the number of uninsured Americans has risen. The debate on health care tends to focus on tangible details, such as lengths of hospital stay for new mothers. Also since 1993, fundamental conceptual issues have largely been avoided. One reason is the annoying reality that it is not possible to simultaneously maximize access to care and quality of service and minimize costs. Second, we must acknowledge that, de facto, society regards some health care services, such as obstetrical services, as social goods or inherent primary rights, and others, such as liposuction or psychoanalysis, as discretionary commodities.