For the past 10 years I have worked as a doctor in Hawaii, first as a family physician in a rural clinic, then as an emergency room doctor full time while serving in the state Legislature.

For 10 years I have witnessed the flaws and risks of our health care system from the perspective of a doctor, a state legislator, and for the past three years as a husband and father.

Over 45 million Americans are excluded from our health care system. We pay more for health care than any other country in the world, and get less for our money than any other developed country. Costs continue to soar, threatening to bankrupt our economy and millions of American families along with it.

Why? Because health care in America is dominated by a private insurance industry whose profits depend on excluding people from the system. These profits come from denying coverage to the most vulnerable patients — the chronically ill and the working poor — and by denying "unnecessary" procedures or treatment for "pre-existing conditions" to those who can afford coverage.

And who ends up paying for the the people who are excluded? We do. The taxpayers.

We pay for their care in state hospitals and publicly funded emergency rooms that take patients who may not have seen a doctor in years because they are excluded from the private insurance system. Taxpayers end up paying for health care in the least efficient, most expensive settings, for problems that might have been prevented years earlier.

When I recently received the honor of being named Hawaii Physician of the Year, I was moved to speak out more strongly on health care reform.

These are five specific actions that should be a part of the president's 2009 landmark efforts:

1. Prevent insurers from denying anyone insurance based on pre-existing conditions.

2. Pass the "public option" if at all possible to force the insurance industry to evolve or go extinct.

3. Make health care more efficient through the comprehensive implementation of new technology, such as electronic medical records.

4. Review medical liability rules in our country to eliminate defensive medicine.

5. Pay all of our physicians' and nurses' school loans over 5 years if they commit to caring for our most vulnerable people, in a greatly expanded National Health Corps.

Finally, the White House should use its substantial influence to usher in a new era of personal responsibility for our own health. Specifically, smoking cessation, obesity prevention and substance abuse treatment must become national health priorities. This will contribute greatly to making health care affordable in America.

In my work as an emergency room doctor, not a single shift goes by where I don't see a family without private insurance forced to make the impossible decision of choosing between getting care for their child and paying their mortgage. No one in our country should ever face this decision. We can do better than that.

Reforming our system might seem daunting, but it's nothing compared to a trip to the emergency room with a child who can't breathe, knowing the bill could bankrupt your family. Or imagine having a heart attack but choosing to stay home because you don't want to spend your daughter's entire college savings account in three days.

We must reform our health care system now, and that reform must include fundamental changes in the private insurance system.

The future of America's health care system and our country's economic survival depend on it.

Josh Green is an emergency room physician in Kohala and Kau Hospitals on the Big Island and serves as state senator for the 3rd District, West Hawaii. He wrote this commentary for The Advertiser.