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>> You are correct Sir. If I had more than 5 choices available that would be one. I think the worst offender on the list is probable the Insurance companies. What do you think? <<

I know it sounds like a cop out, but I honestly can't separate out one single factor that is the primary culprit of the dysfunctionality of the U.S. health care system.

The insurance companies have to comply with 50 different state laws which really jack up the cost of their bureaucracy. Add to that their expectation of a decent return on investment (a reasonable expectation given they are private businesses as long as the profits are reasonable and ethical) and you have high built-in costs there. The profit motive can be good for providing incentive to cut costs, but not if it means denying medically necessary treatments to achieve it.

Also, Big Pharma is an understandable target as well-- and to a significant extent they deserve it -- but let's not forget that (sometimes) excessive regulation of drug prices in most other nations means that the drugmakers have to look at the U.S. market as the primary means to recoup their investment in the drug's R&D (as well as the R&D costs of failed medications). One thing I really do wish would go away is all the "ask your doctor" advertising and the schmoozing and inducements some drugmakers provide for doctors. Okay, that's two things.

The individual market is crippled by being so fragmented, largely (but not completely) because of the tie most people have between employment and group health care. Group health care, it should be noted, removes most financial incentives (carrots *and* sticks) for making good lifestyle decisions. And "adverse selection" in elective individual policies makes it hard to insure the "bad risks" at almost any price.

I've already picked on Congress, sort of, plus they are such an easy target. Not much to add there. They go where the campaign contributions go.

And let's not forget the trial lawyers. Seeing all those daytime network TV ads for local ambulance-chasing attorneys makes me sick, as getting people what they "deserve" (and the commercials alwayts imply we "deserve" a big payout) costs everyone else -- doctors, insurance companies, other purchasers of health care and health insurance. There's a place for litigation, but IMO the bar needs to be reset a bit higher (and frivolous suits should go to a "loser pays" model). Not only are there the direct costs of lawsuits, but also there are indirect costs (higher malpractice insurance causing medical costs to rise, as well as "defensive medicine" leading to many unnecessary and duplicated procedures.

Then there are the lobbyists of the insurers, the drugmakers and the trial lawyers...but in order for them to be effective, there must be legislators whose votes can be bought. And there will also be partisan ideologues who can miraculously defend some of these and not the others.

Somewhat tied into the fragmented individual market is the fragmented system of payments which duplicate bureaucracies at great expense. "Single payer" is usually a code word for a more socialized health care *delivery* system, but it doesn't have to be really socialistic if only there were a more simple model for paying into *one* administrative system (or at least a much smaller number of them).

And while there are legitimate privacy concerns, the lack of electronic medical records means that many physicians have to order duplicate tests to be performed within a relatively short period of time, also adding to expense.

The bottom line is that there are flaws all over the place, and like the little Dutch boy trying to stop the leaks in the dikes, you can plug one hole with your finger and the others may just leak more. Neither party and no single ideology can fix the patient the way the people want it to be fixed (assuming that's possible).

We want the very best care, the very highest technology and the most advanced medications, and we want it all to be widely available (not rationed) AND affordable. Well, some things will have to give. Top-quality, highly accessible, affordable: pick any two. Seeking all three WILL require some compromises in two or more of these areas.

#29
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