I've always been reasonably healthy, don't need to visit the doctor much, and have never had major surgery. Consequently, my evaluation of our health care system mostly comes from second-hand reports: conversations with family and friends, articles in newspapers or magazines or blogs, statistics found online. The upside of this situation is that I have some detachment and perhaps a little more objectivity than I would otherwise, but the downside is that I am not personally confronted with the frustrating trade-offs that often characterize health care in the US and so I'm not required to think too deeply about them. That's changed now that I have a young child. We recently visited the ER (he's fine) and in the aftermath I found myself wondering about the competing incentives that drive decisions related to medical care, particularly in an urgent or emergency situation.

Let me actually start with two anecdotes about health care that I recently stumbled across online. The first , from Balloon Juice, favorably compares the availability of care in the US to that in countries with centralized systems: 

You’ll remember that, a couple days ago, I told you my dad had a minor stroke because he has 69% blockage in his carotid artery.

Well, today he found out that they will not operate on him. He has to have 90% blockage in order to be considered.

If you want socialized medicine in this country, know what you are getting into. The decision about my dad was not made from a health perspective. If it was, he’d have been in the operating room already. It was made from a rationing perspective, and I am pissed off royally. It would not have happened here.

There  is some discussion in the comments about what is the standard within the US to operate under these circumstances, but let us abstract the general point being made: if one has good insurance in the US, it is often easier to obtain surgery in "borderline" cases than it would be in a "socialized" system. (The caveats there are obviously of prime importance.) This is a reasonable conclusion if there is a cap on the total cost of health care that is less than what we would pay were all the "borderline" cases to result in surgery. I don't know if that's what universal health care would look like in the US; presumably there would be some sort of method of containing costs, meaning some restriction of access for borderline cases, but we as Americans seem to demand a very high standard of care. Maybe the compromise would be a single-payer public system providing basic and emergency care alongside a private system providing elective, cosmetic, or "expert" care that people could buy into (via insurance, I suppose).

The second story, from Obsidian Wings, discusses an emergency surgery:

As you might have noticed, I haven't been around for the last few days. This is because, after getting hit with excruciating pain late Sunday night, heading to the emergency room early Monday morning, and having a series of increasingly high-tech tests, the doctors decided I needed emergency surgery, which I had Monday night. Nothing serious (though it would have been had I not gotten treatment), no complications, and I seem to be recovering nicely.

[...] Luckily, I do have health insurance. That meant that I was able to focus on doing what I had to do to get better, and that I was not tempted, for instance, to skip out after the initial tests, which were equivocal. (I did wonder, as they wheeled me into the Department of Nuclear Medicine for the last test, whether this was some of that unnecessary care I sometimes read about. I was wrong: that was the test that led them to decide to operate within the hour.)

There are two points to take from this: first, the state of insurance coverage can impact whether the patient wants high-tech and costly testing, which can impact whether such tests are performed, which can impact whether surgery is done. Second, those tests can uncover potentially life-threatening conditions that wouldn't simply disappear were the tests not ordered; there would be emergency care provided down the road regardless, except that the patient would face much greater risk, potentially including death. Not discussed here is the incentive from the hospital side to conduct such tests, which can make money (as well as potentially saving lives) -- in a perfect world decisions about medical care would not be affected by the ability of the patient to pay, but one wonders whether un/underinsured patients should expect to be offered the same tests as those with good insurance. On the flip side, patients paying out of pocket may be given a discount, suggesting that the cost for insured patients is inflated; either insured patients are essentially subsidizing the others, or the hospital is taking a loss due to un/underinsured care. Finally, the hospital wants to shield itself from lawsuits, and the best way to do this is to run lots of tests.

Our little adventure began Friday evening, when the baby became unusually irritable and started crying a lot. He's normally extremely happy, so this was odd. He didn't sleep well and continued to fuss and cry in the morning. He's had a cough for a while, and my wife and I both got sick earlier in the week but he didn't, so one possibility was that he was just sick. He also fell over at day care Friday and bumped his head -- he's at the stage where he can sit up and crawl around, and I guess he just tipped over. (Our day care is generally excellent, we're quite pleased with it.) There was a little mark and minor bruising. Anyway, being the first time parents that we are, we figured we should just check in with the doctor and see if there was anything we should be doing. Since it was a weekend the pediatrician didn't offer normal clinical hours, so we called urgent care. They were concerned, probably predictably, about his head. They didn't have staff available at that time to conduct the tests they wanted to do and so they told us to go to the ER.

He was admitted to the ER with a normal temperature, and the doctor found no signs of an ear infection (good, since he'd had one earlier that we treated) and no signs of pneumonia; from visual inspection he seemed fine. He wasn't projectile vomiting, which could have indicated serious head trauma. The doctor wanted to be sure there was no bleeding or swelling in the brain, so he ordered a CT scan . I suppose this is typical defensive medicine. It wasn't much fun for the baby, he had to get strapped down, but to paraphrase Dizzy Dean they scanned his head and found nothing. That was a relief, anyway, and so we headed home. Eventually the baby cheered up (although he's still a little cranky on and off) and we're left guessing as to what happened: maybe he was sick, or constipated, or teething.

Our insurance will presumably (hopefully) pay for most of this visit, which is convenient for us because apparently CT scans in particular are expensive. In the US, anyway . That link mentions that the cost is much lower in India, although the service provided is essentially identical. Probably it costs more to train the people who conduct/interpret the test in the US, and I gather the machine is priced a bit higher, but there are other factors driving up the cost here, as discussed in that piece and in the links. Maybe the hospital sees a way to make a bit of money in this area to offset expenses in other areas, and since insurance usually covers most of it the patient is more inclined to take the benefit of the test (which can be substantial, obviously) and not worry so much about the additional expense. One can understand why insurance companies feel the need to referee medical decisions, even if one is unsympathetic to their bottom-line perspective. From an abstract or uninvolved point of view I guess I could say that the CT test may have been unnecessary in our case, although that's easy to claim in retrospect, but of course we didn't have an abstract perspective and when it's you or your spouse or your kid on the line the definition of "unnecessary test" changes rather dramatically.

This experience hasn't given me any brilliant insight into how we should fix our health care system, but it has provided me with a better understanding of the problems. It seems to me that the players involved acted rationally within the system at every stage, and from my perspective the outcome was good, but was it cost-efficient? Most of the proposed reforms being debated by politicians at a national level involve making changes around the margins: lowering costs on patients by prohibiting insurance companies from discriminating based on pre-existing conditions, lowering costs on small businesses (and insurers) by covering catastrophic care at the federal level, lowering costs on hospitals by reducing the ranks of the uninsured, lowering costs in general by streamlining care and making efficient use of technology (for example making medical records easily available in electronic form to hospitals to reduce the need for shooting-in-the-dark testing). Basically these ideas spread out some of the cost of health care over all taxpayers (so it is paid for on a progressive scale) while retaining some of the cost locally to preserve incentives to minimize expense. This would certainly improve things, but isn't going to radically change the nature of the tough choices we'll need to confront. We'll need to tackle how we as a society feel about end-of-life care, how we handle coverage versus care, how we encourage a healthy lifestyle. We'll also need to confront the reality that having immediate access to outstanding quality care is going to be expensive, and if we want to pay for that then we'll lose something elsewhere: either taxes will go up or services will go down. No free lunch, unfortunately.

I know some people here have previously discussed their experience with our health care system (maybe they'll provide links in comments) and I imagine others here have their own anecdotes, either first-hand or otherwise, that shed further light on the issues. Like I said I have no easy answers but maybe we can come to some consensus as far as identifying problems and potential improvements.