Rachel Maddow has it right

See: http://politicalirony.com/2010/02/26/rachel-maddow-explains-our-health-care-system/

    Her interpretation is patently obvious and supports what I (and many psychologists) have long contended: it's all about the incentives.  In an era of indemnity insurance (pre HMOs), doctors provided a service and insurance companies simply paid the bills.  Not surprisingly, the incentive for doctors was to provide more, arguably unnecessary, services, leading to skyrocketing healthcare costs.  When we moved to a capitated system, the incentive reversed: if a doctor or group practice received a fixed sum of money per individual per year, there was every incentive to provide the minimum service that didn't lose customers (at least the low utilizing fraction) at the next annual enrollment period.  For-profit insurance companies are obviously in the business of making money.  They only way they do that is by maximizing premiums and minimizing layout.  I don't know the details that constrain not-for-profit insurance companies...I assume they must refund "profits" or use them to decrease premiums in out years.  But there are always loopholes and business practices to divert funds.  Internal incentive structures still bias towards providing the minimum permissible service.

    There are many more "incentive imbalances" throughout the system - it would take a long missive to describe them all - but suffice it to say there is no perfect solution.  Consumers want low healthcare costs for all, but the absolute best healthcare for themselves.  Physicians and healthcare providers want to provide appropriate care but expect to earn a respectable living for their effort and don't want to get sued for missing something.  Insurance utilization reviewers want to approve needed care, but their performance reviews are benchmarked to fiscal goals.  Legislators want to do the right thing for their constituency but re-election is predicated on support from special interests and motivated voters (whose selfish interests are not necessarily in the best interest of society at large).

    From my perspective, the goal is to balance all the incentives to achieve the desirable goal...and therein lies the rub.  We as a society are not sure of, or are divided about the goal.  Those (like myself) supporting universal healthcare accept that healthcare is a basic human need like food, shelter, clothing, and safety. Since that is, in effect, how U.S. healthcare operates (i.e., we don't allow people to die by dint of an insurance deficit), we might as well make the system maximally efficient by removing financial barriers to primary and preventive care, set up incentives to avoid unnecessary or low-yield expensive care, and accept that publically financed boutique care for the privileged needs to be sacrificed in favor of basic care for the masses.  Those against universal healthcare are those who either a) benefit from the existing system, b) prefer the known, if flawed, existing system rather than risk what they fear could be a worse alternative (universal) system, or c) are too uninformed or swayed by demogoguery to vote in their own best self-interest.

     Hence, as Rachel implies, we have only to blame ourselves for our healthcare system.  And the only solution in a democracy, short of dismantling ALL publicly financed healthcare and making it a commodity one can obtain only through purchasing or charity, is education.  Educate the masses so they vote for thoughtful politicians.  Educate the masses so they understand the balance of choices (e.g., denying inexpensive primary care leads to expensive downstream tertiary care, denying drug and alcohol treatment as a "lifestyle choice" increases police and penal costs, child and spousal abuse with subsequent loss of productivity, taxes, disability costs, etc...not to mention the humanistic failures).  Educate the masses that, to quote Spock, "the needs of the many outweigh the needs of the few."

    The fact that other countries have found ways to provide better care to their entire population at lower cost shows that this is not a pie-in-the-sky prospect.  All we lack is the education and will to change in our own national best interest.