The US medical delivery system has been coming under increasing scrutiny. As a $2 trillion per year industry in 2007, it has become the biggest business in America even topping defense, automotive and energy. Costs are high and climbing as a percent of the GDP and have been doing so for decades. Medicare Part D raised the debate over pharmaceutical costs. Healthcare reform in 2010 in the form of the Affordable Care Act aka "Obamacare" tweaked the system and generated massive debate.

Are we getting our money's worth? Are there alternatives?

We are paying more in America for medical services than others are around the world. We spent about 16% of our GDP in 2006  to cover 85% of our people. Estimates are that spending will climb to 21% by 2012. Nobody else in the world pays as much as 10% to cover everybody, even the French.

Looking at the OECD ratings you can see that Americans who can afford good insurance coverage are getting excellent health care services. However there are tens of million of Americans without insurance coverage who are being left out.

Structurally, healthcare in the United States is provided by private companies and doctors through a regulated marketplace and financed by private employer provided insurance programs. Government insurance is provided for the elderly, disabled and poor. This is a different approach from most of the other OECD countries where healthcare is more socialized.

That brings us back to the goal. What do Americans expect from their health care delivery system? Do we want to divide the pie evenly or do we want to make the pie as big as possible? Traditionally Americans have preferred the "big" alternative and done everything possible to improve the quality of the top end care. Research centers, top surgeons, big pharmaceutical companies with more research and development, top medical schools, experimental equipment, procedures and tests all come from the decision to go "big." They all add to the price tag. If this is what we want we are getting it.

Regulation and litigation allows only the highest standard of care. It is as if we regulated the auto manufacturers and allowed only the "best" cars on the road. You could either buy a Mercedes or stay home.