On Fox News Wednesday, Sen. Hillary Clinton told the network's Bill O'Reilly, "If we don't get universal health care, we will continue to bleed money." Funny. The more Washington politicians promise to control health care costs, the higher they go. As humorist P.J. O'Rourke famously said, "If you think health care is expensive now, wait until you see what it costs when it's free."

Clinton and Sen. Barack Obama both promise to provide access to health care for all Americans by mandating that employers provide or contribute to the cost of health plans for employees. Clinton would mandate that all uninsured adults buy health care; Obama has no "individual mandate." Both candidates would offer health care for all children, subsidies for adults and would require insurers to cover everyone, regardless of health.

Somehow they propose to offer and subsidize more health care without raising costs for the majority of Americans who already have it.

What next? Consume more calories, weigh less?

Both Democrats suggest that prevention will contain costs. But as the Washington Post reported last month, with a few exceptions like childhood vaccinations, health economist Louise B. Russell's 1986 work, "Is Prevention Better Than Cure?" found that "prevention activities tend to cost more than they save. Since the book's appearance, her observation has been borne out by studies of hundreds of interventions — everything from offering mammograms for all women and prescribing drugs to people with high cholesterol to requiring passenger-side air bags in cars and shortening the response time of ambulances."

Of course, prevention is a wise course. It extends and improves the quality of people's lives. But in the real world, it costs money. And it's worth it.

How can Americans control health care costs? I asked Sen. Tom Coburn, R-Okla., an obstetrician and family medicine physician who prefers to be called Dr. Coburn. He answered that there are two ways to control costs — through government, a la Clinton and Obama, who will have to rely on federal "micro-managing and (eventual) rationing," or through the marketplace, a la McCain. While the marketplace is not perfect, it beats rationing and bad regulation.

The McCain plan would provide an annual tax credit of $2,500 per individual or $5,000 per family. The idea is to encourage families to buy their own health care plans — preferably plans that save consumers money when they follow healthy lifestyles and make smart economic choices.

Unlike Clinton and Obama, McCain would not require that insurers cover people with chronic illnesses. Instead, McCain proposes state "guaranteed access plans" for those patients.

Politically, Plan McCain may be suicide. Clinton and Obama have kept to the current employer-based system — which gives workers the happy illusion of not paying for their health care, when in fact it comes out of their paychecks.

Like President Bush, however, McCain has concluded that the best way to curb health care costs is to return the incentive to save to patients. Because when you know a doctor's visit will only cost $25 and that you won't have to pay for a test you may not need, you have no incentive to economize. That's the problem with the status quo: The cheaper we make it look, the more it ends up costing.

The way Americans look at health care has been distorted by a system that cuts costs where they are least onerous. Gone is the day when patients paid for annual medical exams and insurers picked up the tab if a family member became seriously ill. Now you don't have to be sick to be subsidized, and workers have come to expect someone else to pick up the tab for routine care, minus a modest co-pay.

Credit McCain for proposing to make the process transparent, so that people have a more personal stake in the care they receive. To the extent that adults buy their own policies, they will be free to work wherever they choose, and they will no longer be bound by their health care.

Also, just maybe instead of scorning what comes cheap, Americans will come to appreciate what they pay for.

When I hear middle-class Americans complain about how they want Washington to do something to pick up their health tab, I always want to ask them: If you don't want to pay for your own health care, what makes you think someone else wants to pay your doctor bill?

E-mail Debra J. Saunders at dsaunders@sfchronicle.com. To find out more about Debra J. Saunders, and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate Web page at www.creators.com.

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