What you say sounds reasonable, as far as generalities and high concept go; but it's contradicted by the hard facts of the results produced by the two approaches to health care. American life expectancy is lower, infant mortality higher, fewer hospital beds per capita, tens of millions of Americans have limited access to medical services...and we pay twice as much for it, whether measured in absolute dollars or as a percentage of private spending. A factor of two is hard to explain away by nibbling at the margins and questioning how the cost is being defined.

Does it include research and development? Costs of approving drugs? The creation of advanced health technologies that other nations get to buy off the shelf?

The question of R&D is relevant only to the degree that it's subsidized by the US government and thus should be charged specifically to Americans. If it's performed by private industry then the cost should be amortized over all health care consumers globally.

One service that the US does perform for the rest of the world is to have very high standards for pharmaceuticals and medical procedures, so that those things developed in America are of the highest quality. Given that pharmaceuticals seem to cost more in America than elsewhere, perhaps we are subsidizing more than our fair share of the cost. But the solution to that is simple: Allow the free market to equalize prices by allowing Americans (including American health organizations and government agencies) to buy pharmaceuticals from wherever the cost is lowest. We only pay higher prices because we let the pharm companies get away with buying protectionist legislation.

The reason national health care systems go broke is because they are, in economic terms, an engine with the accelerator wide open and no governor. When something is perceived as "free," the demand goes up endlessly.

What's fascinating about that paragraph is that if you substitute "employer-paid" for "national", you're stating the exact criticism of the high-quality health plans we used to enjoy 20-30 years ago, and the very justification for HMOs and "managed care". The acknowledged purpose of those "innovations" was in fact to ration health care in the interests of holding down the costs.

I think we ended up with the worst of all possible worlds by giving the power to ration to private industry. HMOs are accountable only to Wall Street, and Wall Street is just the least-common-denominator abstraction of millions of investors: An Instatiable Hunger personified. Wall Street's objective isn't to optimize health care delivery, its objective is to wring the maximum possible profit from it.

And you wonder why our health care costs are so outrageous? What else would you expect when you give a business the power to control how much product and service it will deliver for a given price? The incentives built into our present approach guarantee lousy health care.