Wall Street Journal ended an editorial on RomneyCare 2.0 (WSJ, Aug. 6) with this ubiquitous health care lament, "Everyone agrees that the health system needs to deliver medicine more efficiently and be more accountable, but to whom?" (emphasis added).

The obvious need for greater accountability in health care receives more recognition and less deep consideration as to "how" and "by whom" than almost any other aspect of patient care in the quality of health care literature. However, WSJ editors might have made a more cogent point of need if they had said "by whom" rather than "to whom". Perhaps a more elementary discussion of accountability in health care will be beneficial.

Authority: the power to control, command or determine.

Accountability: responsible, answerable, explicable.

      Explicable: capable of being explained.

State governments create state health care agencies and empower those agencies with authority to regulate their expressed portions of that state's health care delivery system. All 50 state medical examining boards are over 100 years old. Yet accidental deaths that occur in state authorized hospitals and surgery centers receive NO immediate review by a source of authority. Why?

Accountability (meaningful accountability) can only occur in the presence of sufficient authority. Problem is, no state can explain (explicable) its current mechanism of health care accountability that must be established through its system of health care authority.

Contributing to this morass of incompetence is the following inconsistency; the most vocal elements actively seeking to improve the quality of health care, both on a national and state level, are agencies and organizations with NO (zero) authority within any state's health care system, while those same states' agencies which were created and given regulatory health care authority remain relatively silent. Examples of this dichotomy at both national and state levels are:

American Medical Association (AMA) and American Hospital Association (AHA). These are both regularly sought out as sources of health care expertise despite the fact that, as membership organizations, neither one has the ability to exert true authority over any of their members, doctors and/or hospitals. A member of an association need only to resign their membership if threatened with review of questionable behavior by the parent organization. Therefore membership organizations are toothless regulatory entities.

At the same time, has anyone noticed the silence and lack of active participation in the efforts to improve the quality of health care being offered by any state medical examining board, or for that matter, the Federation of Medical Examining Boards (FMEB)? Those who voice concern for the obvious need for greater accountability in health care should first determine who is responsible for establishing health care accountability and how might greater health care accountability thusly be established.

When people get tired of having their state governor and legislature allow accidental deaths in hospitals and surgery centers receive NO accountability and instead be ignored by their state's health care regulatory apparatus then perhaps a new day in health care accountability will emerge. A first step toward this end might be to have any state first demonstrate even the existence of their state's health care regulatory mechanism.