With the health reform debate being front and center for the last few months, as a culture, we have  pretty much settled on the meme that the insurance companies are the villains. Another meme is that the villains  are American consumers and agribusiness because they are complicit in the creation of unhealthy lifestyles.

While I don't necessarily disagree with these arguments, I am concerned that the debate does not take several other relevant issues into account. 

1. Cost of health care. The average cost of obtaining a reasonable health-related service must be a reasonable multiple of average per-capita income.  I realize that there would be a great deal of disagreement about what the word "reasonable" means in this context. But, the way I look at it, current prices of health care are in the realm of the $600 toilet seat. And there is agreement that that is not reasonable.

I listened to a podcast last week about a couple who incurred over $400,000 in medical expenses for a difficult twin pregnancy.

Earlier this year Greg was laid off. Knowing Heather was pregnant with twins, he arranged to continue their coverage with the same provider. They paid insurance premiums directly to the company. The insurer took the money, but after the delivery, they refused to pay the claim. And it is a lot of money: more than $450,000.  

That the conduct of the insurance company (United Healthcare) is outrageous is a given. 

But, shouldn't we also be talking about what can be done to bring the prices of such procedures to a more "reasonable" level? 

2. The case for rationing. When scarce resources must be allocated among a large number of people, there will be rationing.  As a society we should strive to allocate those scarce resources as equitably as possible. 

As shown in the example above, we have rationing even now. It is just that it is the insurance companies that are doing the rationing and it is being done in the most unscrupulous of ways. They refused the medical claims on the flimsiest of grounds after first confirming that the couple was covered, and after accepting the premiums for months without any qualms.    

We need to accept that everybody cannot have everything. Only then will we able to think rationally about what needs to be done to make allocation of scarce resources consistent, predictable and fair.

3. What is a covered "medical" condition or what is "medically necessary" care? Last week I watched an ad on TV for a new drug (latisse) that grows the "patient's" eye lashes. I don't know if this would be covered by insurance. I feel that such medicines - solutions in search of a problem - should NOT be covered. The same goes for a different prescription drug that removes facial hair (vaniqa).  And even viagra. 

4. Insourcing and offshoring health care and pharmaceuticals. If the cost of health care is high, why don't we apply "free market" ideas to this industry and add more practitioners? We could create new medical schools and flood the market with more primary care providers, we could import ready, willing and able doctors from other countries, and we could send patients to other countries where care is cheaper. As for pharmaceuticals, we could import them from where they are available for the lowest cost. What is good for manufacturing and IT should be good for health care. No? 

5. Why are republicans (or at least the reasonable ones among them) not troubled by health insurance tied to jobs? I would have thought they would be in favor of anything that relieves employers of the burden of providing health insurance to their employees, and making businesses better able to compete in the global marketplace (which is the holy grail that is, these days, used to justify any pro-corporations stance - like "too big to fail") .    

6. What is the opportunity cost of high health care costs? In other words what are we foregoing because of the crazy way in which it is currently structured? There is a great hue and cry every time there is an attempt to increase the minimum wage. The argument is that businesses will hire fewer workers. I don't agree with the argument when it comes to the minimum wage. But, extending the same argument, I cannot help wondering about the effect of the high cost of health insurance costs on the economy's ability to create and sustain jobs.

By the same token, surely the high cost of health care reduces consumers'  ability to spend money on other goods and services.  Which again ties into the health of the economy and its ability to create jobs.    

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I wish there were published tables of what insurance will pay for each procedure. This would give patients and their families the opportunity to rationally elect the procedures they want even though some of those procedures are above and beyond what the "system" will cover.   And, it would permit patients and their families to live and die with dignity.

After all is said and done, isn't that what all this is about?