The United States spends far more money on health care than any other country. In 2010 we spent $8,233 per person, about 2.5 times the Organisation for Economic Cooperation and Development (OECD) average and half again as much as the next most generous country, Norway.   The total cost, $2.6 TRILLION dollars, was 17.6% of our GDP, one-and-a-half times more than those “socialist hellholes” Denmark, France, Canada, the Netherlands and almost double the U.K.

Some people-notably the well-insured and conservative commentators-think this is just fine. “We have the best health care in the world, but government is trying to take that away from us and give it to lazy people.” There will be rationing, death panels, people dying in the streets and your wife will certainly die from breast cancer.

Others, like the people actually paying the bills (namely, Uncle Sam), realize spending all that money doesn’t get us much.  The United States is 51st in life expectancy; our outcomes are about the same as countries with single-payor systems; our pharmaceuticals and hospital procedures cost a lot more. We’ve also rationed health care for decades based on one’s ability to pay, but that’s a separate topic for another rant.

So, somewhere along the line government decided that we should cut our annual health care expenditures. American Medical News published an article I wrote back then warning health care reform wouldn’t be successful because reformers were asking “What kind of health care do you want?” rather than “How are you going to pay for it?”

Spending less money on health care means paying less, and/or doing less. That is simple mathematics. So who is will be the first to accept “less”?

• Will patients accept less care than they want (as opposed to the care they need)?
• Will hospitals accept less revenue?
• Will physicians accept lower salaries?
• Will insurance companies agree to lower premiums?
• Will pharmaceutical companies accept less money for their already overpriced drugs?
• Will manufacturers sell MRI machines and surgical robots for less?

Nothing is likely to happen without tradeoffs; everyone will have to give up something.

If I was contemplating a career in medicine instead of looking at retirement, I’d agree to a lower than expected salary in exchange for free medical school training, decent working conditions and getting the plaintiffs’ attorneys on a very short leash.

• I wouldn’t need to make a hefty salary if I didn’t graduate with $250,000 in school debt.
• I would provide much better service if I wasn’t on call every night or every other night.
• I would be able to do what I thought was right rather than wasting a lot of money covering my ass.

But first we need a national dialog about our health care system.  What do people want?  More importantly, how do they propose paying it?