Plans to reform Bermuda’s healthcare system seem to be progressing, with the publication last week of public feedback to the proposals and the appointment of task forces to now start putting place changes.As Health Minister Zane DeSilva said, no one disputes the idea that all people should have access to healthcare. The big challenges concern cost and who should pay for it.Part of the frustration lies in the fact that the cost of healthcare consistently rises at a faster rate than the overall rate of inflation. No one seems to be able to explain why this should be, and the Health Plan does not have many ideas about how to cap costs. Instead it proposes a system whereby people in essence would pay based on their means.This marks a sea change for Bermuda. To be sure, land tax rates rise based on value, And the former Medical Clinic gave free to those who could not afford to go to a doctor, and that was paid for by other patients or the taxpayer. But otherwise progressive taxes of the sort proposed here do not.And there is something galling about the idea that one person should pay less for a procedure than another person would. Since the procedure itself costs the same regardless of the patient, why would there be a difference? Having said that, there is merit in the idea that people who lead healthy lives should pay less in insurance premiums than those who do not, and who will probably end up requiring more health services throughout their lives.Quantifying this will be difficult, but there could be a discount for non-smokers, for example, since there is a proven link between smoking and ill health. Employers and others could also receive benefits for having a healthy workplace, whether this takes place through having healthy cafeteria food, exercise regimens or other low cost healthy alternatives.All of these measures are aimed at preventing ill health and encouraging wellness. That in turn should reduce the cost of and thus the use of hospital services, which in turn should reduce costs. None of this is an exact science, but the long term solution to reducing costs demands better public health.A book called “Efficiency, Justice and Care” discusses the problem of an “incompatible triad”: The sign in a garage forecourt says: “We provide three kinds of services. Cheap quick, and reliable. You can have two, but you can’t have three. If it’s cheap and quick, it won’t be reliable. If it’s quick and reliable, it won’t be cheap. And if it’s cheap and reliable, it won’t be quick.”The same principle applies to healthcare. Everyone wants it to be universal, cheap and of high quality. It can be universal and efficient, but not of high quality. Or it can be universal and of high quality, but it won’t be efficient. Or it can be efficient and of high quality, but in that case it won’t be universal.So far, the proposals for reform have not tackled this quandary, except through the proposal for means testing.That will be politically difficult and expensive. Mr DeSilva’s task forces have their work cut out.