s the second session of the 109th Congress began in January 2006, the congressional approval rating had fallen below 30 percent, and the President’s approval hovered in the low 40s. An unpopular war in Iraq continued with daily casualties, deaths and no clear strategy for an end. At home, unsecure borders and seemingly unresolvable problems created by illegal aliens were the cause of increasing public anger. While I continued my congressional fellowship, my wife worked Tuesdays at the White House answering telephones. The volume and intensity of telephone calls from the American public tracked their increasing sense of frustration. While Americans are frustrated by events such as a war that cannot be won, they are even more frustrated by the sense that neither the president nor Congress appears to be able to resolve issues.

For most of the 20- and 30-year-old congressional staff members, the war is a very small part of the multitextured tapestry of complex issues with which they work every day. Each congressional office has a staff of five or six legislative assistants who share the 30-40 issues each congressperson needs to be informed about on a daily basis. A health care legislative assistant also may be responsible for tax, budget, pension, Social Security and retirement issues. For many there is a sense of amnesia about wars that cannot be won.

A policy committee trip to Walter Reed Medical Center abruptly refocused my memory. The sickly sweet smell of sweat, urine and open wounds twisted my stomach. The sights and sounds of head-injured multiple amputees brought cold sweat to the back of my neck just as they had when I made postoperative rounds in Saigon decades ago. My awareness of war is very different from many of my coworkers.

As Congress returned from the New Year’s recess, an event occurred that left some of my coworkers in tears and my job in jeopardy. Tom DeLay, the House Majority Leader, resigned amid allegations of improper relations with lobbying firms. Two members of the congressional leadership and a committee chairman campaigned to replace the majority leader: Rep. John B. Shadegg (R-AZ), Chairman of the Policy Committee (for whom I worked); Rep. Roy Blunt (R-MO), the Whip; and Rep John A. Boehner (R-OH), Chairman of the Committee on Education and the Workforce. Each candidate had a constituency but lacked a clear majority. The campaign for leader paralleled the strategies of all elections, solidifying constituencies while trying to persuade the undecided. Rep. Shadegg’s personal and policy staff became his campaign staff. The workday for most congressional staff begins before 8 a.m. and extends well into the evening. For the several weeks of the campaign, we stayed past midnight, preparing campaign materials, letters and briefing packets for members and background pieces for the press. The personal staff in a congressional office is a close-knit family.

The first ballot had produced three candidates who received a majority of the votes but no single winner. Before the second ballot, Rep. Shadegg withdrew, allowing his supporters to join in electing Rep. Boehner as the Majority Leader. The election demonstrated an example of strategic alliances in the political process. Mr. DeLay’s resignation diminished the focus of public attention on congressional corruption. The election of a new leader, however, failed to restore public confidence in the ability of Congress to resolve issues.

The majority leader race ended Rep. Shadegg’s tenure as Chairman of the Policy Committee. I was invited to join Rep. Shadegg’s personal staff, helping with efforts to bring the Health Care Choice Act (H.R. 2355 and S.1015) to a vote by the House.

The Health Care Choice Act, sponsored by Rep. Shadegg and Sen. Jim DeMint (R-SC), would amend current law to allow for interstate commerce in health insurance plans for the individual market. The bill would allow individuals who reside in one state to buy affordable health insurance plans from other states. The content of insurance plans is determined by state governments that mandate which benefits, medical procedures and practitioners must be reimbursed <www.heritage.org/Research/HealthCare/wm1164.cfm>. Each mandate increases the cost of a basic policy by only 1 percent to 3 percent; it is their cumulative effect that compounds the cost of health insurance.

The Health Care Choice Act was passed by the House Committee on Energy and Commerce, with support from a number of groups favoring affordable health care for individuals. It was opposed by organizations that want specific mandated benefits for specific health conditions or for specific provider groups. In general those who oppose the bill would like to see the cost of benefits used by small groups of individuals spread over all purchasers of health insurance.

In order to confirm the continuing support of the Executive Branch for affordable individual health insurance, another staff member and I went to the White House’s Old Executive Office Building to meet with Roy Ramthun, Special Assistant to the President for Economic Policy. After nearly an hour’s discussion with Mr. Ranthum, we were politely told that the president would defer to Speaker of the House Dennis Hastert. We then met with Speaker Hastert’s health policy director to determine the speaker’s priorities for bringing the bill to the House for a vote. He indicated that although the speaker was eager to bring the bill forward, the speaker’s current policy is to bring forward only those bills that have an assured majority of 218 votes.

Because of the sensitivity to pressures from opponents on members in closely contested re-election races, much of the campaigning for the bill was left to supporting stakeholders in those districts. My efforts were directed to keeping supporting groups, such as the Council for Affordable Health Insurance, informed and up to date. I was also able to draw on help from coalition contacts that I had made as a state campaign steering committee member during the presidential election cycle as well as organizations representing self-employed individuals in my home state.

Subsequent meetings with uncommitted members confirmed that although the bill had 210 supporters, pressure from groups favoring mandates would make it difficult to gain additional supporters before November. Philosophical divisions over the fundamental question of the purpose for insurance are clear. We are a nation closely divided on many philosophical issues. The power of alliances was made clear to me. The challenge of providing affordable individual health insurance remains unresolved.

During my time on Capitol Hill, I also was an observer to Congress’ work on other challenging issues. The federal response to Hurricane Katrina raised issues regarding federal preparedness and response to naturally occurring disasters. The events of 9/11 raised issues regarding our preparedness and response to human threats. Resolution of these preparedness issues has proceeded slowly. Competing agendas within agencies, congressional committees, the House, Senate and the administration have not been resolved, and some would question whether we are any better prepared to respond to large-scale disasters than we were a year ago.

As a physician on the inside, I was no less frustrated than my colleagues in practice by the inability of Congress to resolve issues of critical importance to the profession. A method for dealing with the Sustainable Growth Rate formula for determining the annual update of the conversion factor for the Medicare Physician Fee Schedule remains unresolved. Physician payment under the Medicare program has been an issue since the inception of the program in 1965. Physicians are the only professional group that has a majority of their fees for their professional services regulated by federal price controls administered through a federal rule-making processes.

Throughout my fellowship, I was relatively successful at keeping my identity as a physician secondary to my staff identity. This often resulted in greater candor in the discussions in which I was involved. A committee staff member shared with me that her first assignment in a congressional office had been to work on the Patients’ Bill of Rights. She said, at that time, that her only knowledge of health care was where to mail the check to pay for her insurance. She also shared that the greatest influence (negative) on her work came from a health care attorney who was counsel to a subcommittee. She said she often felt that he pursued his own agenda rather than policies that members wanted. Subsequent discussions with groups of health care staffers made clear that their understanding of health care is strongly influenced by notions of managed care and health care economics currently taught by nonphysicians in schools of public health. Sadly they are often skeptical about information provided by practicing physicians.

Younger physicians and congressional staff are seemingly unaware of the breadth of the total impact of federal price controls and rule-making on the medical profession. They have lost sight of the fact that this degree of federal regulation of a profession is unique to medicine. Perhaps thinking outside the box is difficult if you are living in the only box you have known.

My experience on Capitol Hill has only affirmed my belief that physicians need to understand how the system that regulates and pays them works and how issues within this system can be resolved. Most importantly they need to understand and decide how much of their professional effort they want to continue to subject to federal regulation and price controls. Perhaps the time has come to consider trading the security of Medicare assignment for easing the limitations on balanced billing. This may be a more sustainable approach than expending efforts on formulas for payment using theoretical economic models incorporating variables over which physicians have no control. Physicians must understand how the current system works in order to understand that they have the ability to exercise choice and can enact change in bringing issues to resolution.

Physicians also must understand the system if they have any interest in influencing the effect of government on their lives and their profession. The best way for each of us to begin is by learning how the government affects our daily lives and our practices at the local level.

William G. Horton, M.D., is Clinical Professor of Anesthesiology, University of Washington, and Emeritus Physician, Virginia Mason Clinic, Seattle, Washington.