As with most public issues, there is little connection between the identified problematic symptoms and the popularly proposed and repeatedly attempted solutions. Now that everyone is willing to agree that high health care costs are 'a' problem, let's take the next baby step and analyze their basis. That sounds practical, but if fact, has been routinely ignored. Perhaps half of the population, or those who give opinion on the subject, assume that the costs are the costs, and that a shifting of who pays them is needed; perhaps to a rich uncle. That popular political position grossly impedes discovering and resolving the true problem.

To be fair, embedded in the aim of the 'shifters', or some of them, is an egalitarian notion of compassion, which is not to be dismissed and certainly should be on our agenda. But, wasting financial resources which could be used to provide health care for all is antithetical to that goal. Stop, think. Shifting a much used service/function from the private sector to the public sector can be efficient, appropriate and effective, and may, or may not, be appropriate with health care, however, it is an issue separate from the current problem.

If, today, every health care expense of any kind could be cut by 50%, would we be in such a crisis? Would caring for the indigent be seen as such an overwhelming burden? I think not. Look back thirty, thirty-five, forty years: What portion of our wealth was spent on health care services? That is just a primer to begin analyzing the issue. What is health care? A stethoscope, an exam table, x-ray and EKG machinery? Who is health care? Your doctor, a nurse, a technician?

The production of health care services and products incurs expenses such as labor, capital equipment and facilities, supplies, etc. And there are revenues to cover those expenses; in other words there is a business. As in any business there are lots of expense decisions to be made, and in most businesses those decisions are made in an environment of competitive pressures. A shoe store owner must be prudent in their expenditures, else they will exceed their revenues and become unprofitable, and the business will fail. Businesses in a competitive market know that their revenues are limited by the quality of their products, the actions of competitors, and the value judgments of consumers in that market.

In the United States, the first half of the twentieth century saw consumer value judgments in the market of health care services gradually removed. That occurred as the trend of companies providing health care benefits grew into a nationally established structure for the funding of health care. The shifting of health care payments from individual responsibility to an expense item for business, while for many years provided much comfort to working class Americans, was the seed that grew into the preposterously expensive care we now endure. Once someone else is paying for a service or commodity, our incentive for being knowledgeable as to the value of the entity is eliminated. Thus, not only do we no longer have to make a value judgment, our ability to do so is impaired.

The payments of health care services (revenue for the health care services business), in this newly developed system, were being blithely absorbed onto the balance sheet as a labor expense by American businesses. At the time, it was not a problem, as health care expenditures amounted to less than 5% of the Gross Domestic Product (the total of all of our expenditures on goods and services). It is to be expected that as more of the public received health care services, either through private or public means, health care expenditures would rise as a percentage of our overall expenditures. However, a more insidious effect from this new payment structure began to appear mid-century.

As this nation is so firmly entrenched in the notion that a competitive/capitalistic economy is a good thing, relative to the alternatives, it baffles one (or, at least, me) as to how the fundamental laws of such an economy have commanded such limited attention vis-à-vis the pricing of health care. On this topic, the word competition has only been raised in discussing the business of the insurance industry. The last I checked, no one went to the insurance company office to have their prostrate examined, kidney replaced, chemo-therapy, or any other medical procedure. The growth of the health insurance industry and its emergence into a fixture of our health care system were additional ill side-effects of the movement to employer provided health care. Current generations of Americans have no perspective on and thus no appreciation of the concept of insurance, pertaining to health care. For so many, for so long, the ‘cost’ of health care was, perhaps, $20, and they never saw a bill for the health insurance payments. As the word insurance became synonymous with health, the two have been, to our detriment, intrinsically linked. That was/is a development helped along by the insurance and health care industries; that disconnect of consumption and payment has been the goose that laid the golden egg for almost six decades.

To some degree, there has always been competition among health insurers, much more so than amongst health care providers. But, competition among insurers didn’t become a serious impediment to rising prices until the proverbial ‘shit’ hit the fan, or actually backed up in the pipeline, in the late 1980’s. It was only after uninhibited rises in health care prices reached a ‘red flag’ point on the balance sheets of American businesses that they, as consumers of large scale health insurance policies, began to more acutely eye those expenditures. Up until then, insurers largely were simply insurers of losses/outlays to their clients, typical of any other type of insurance model; not the medical costs inhibitor that they became. But, limiting the competitive argument to the insurance industry is the critical error of those who are charged with addressing this crisis. As most are willing to acknowledge, the price of health care is too high. Unfortunately, steering everyone away from the real problem is the popular belief that health care and health insurance are one in the same.

Health care is a monstrously large industry totally apart from the insurance industry, which simply acts as a transferor of our wealth to the health care industry. Without addressing the economy of health care, sans insurance, the real culprit, high costs will never be alleviated. I would like to expound on this next step, but I must stop, as I imagine I have already exceeded the tolerable limits of this venue.

It is not luck to acquire adequate insurance coverage. Read the contract. A customer can request a copy of the insurance policy to review before entering the agreement. If one does not understand the policy, get some help or ask some questions. If one does not understand what a root canal costs, one is not asking the right people the right questions. So many people are uninvolved in their own health care.

In this country, everyone is free to buy as much health care as they can afford. What's the big deal? That is each ctizens choice. One should not simply complain about the cost of the service one chooses. If the service is unacceptable, do something about it. Negotiate the cost. Boycott the provider. Report the business to everyone, everywhere. The providers are the source of the cost.

When health insurance first began in this country, no one bought it because there was no expensive care. The only reason anyone wants health insurance now is BECAUSE health care is so expensive. When people attack health insurance as the cause of rising health care costs, it is impossible to list all the fallacies with this line of reasoning. Basically, all the well intentioned purveyors of this argument have it backwards.

Sure, but the customer has the choice of not visiting that restaurant again if that pattern persists. Not so with public sector services- there's no competing DMV down the road if your local one is the type where you have to wait 3 hours (that was my experience in getting a driver's permit for my daughter.)