Ezekiel Emanuel is half right . . .

But there's a bit more to the story. He points out that 10% of the population account for almost two thirds of health care costs. As a matter of fact, based on data from the Medical Expenditure Panel Survey, the top 5% account for more than half, while the bottom 50% account for 5%. (Abstract only for the unwashed. This data is 10 years old but it had been stable since 1970. It doesn't change.)

Dr. Zeke wants to make the care of those people more efficient using bundled payment instead of fee for service and care coordination strategies. That's fine, it might save a few percent and make those folks lives a little better. I'll let his argument about that speak for itself if you care to read the article.

But here are some points he doesn't make.

First, you've heard all that yackety yack from conservatives about how if we had to pay for more of our health care out of pocket, people would choose more wisely and we'd save a lot of money. Pish tosh. These people are soaking up tens of thousands of dollars a year in health care expenditures because it's free to them so why not go for it. They are seriously, chronically sick. They have kidney failure, heart failure, complications of diabetes, cancer, or serious congenital diseases. (No, they aren't all elderly, only about half.) People don't get kidney dialysis because they feel like it, they do it as the only available alternative to dying. Making the rest of the people pay fifty bucks to see the doctor isn't going to save diddly, but it is going to make them more likely to end up in the top 5% where they are costing real money.

Second, suppose we could save a few percent on the care of these really sick people. That's better than nothing but it's still only a dent -- and the underlying trend of increasing costs would continue, it would just be set back a couple of years. The problem would not be solved.

Unlike Ron Paul, I am not in favor of abandoning the unfortunate. So what do I propose? A few things that Emanuel doesn't want to talk about because of politics.

First, we need to do cost effectiveness analysis and we need to set limits. This doesn't actually have to hurt people. Do people really benefit if they get three or four weeks of extra life semi-conscious in a hospital bed? I don't think so. That's not where most of this money is going, but it's a chunk. A bigger chunk can come from just knowing what's most effective and setting up enforceable guidelines that prohibit wasting money on useless or harmful treatments, such as angioplasty for people who haven't had heart attacks. People are making money off of this stuff, which is why Republicans won't let us even study the question. Well screw 'em.

Second, we need to invest much more in public health. We'd have a lot fewer people in this situation if we really made the effort to combat obesity, tobacco addiction, and other preventable harms. There's net social benefit from reducing particulate pollution from motor vehicle exhaust, chemical contamination of food (such as BPA from can liners), mercury in fish, food-borne infectious diseases. And a lot more. But that requires spending government money to improve the social and physical environment, and regulating powerful industries. Again, Republicans think that infringes on the freedom of rich people to rob us. See final comment above.

Third, we need to use the buying power of Medicare, Medicaid and public employee health care -- and eventually the buying power of the single payer program that will cover everyone -- to reduce the incomes of overpaid medical specialists and the price of drugs and medical devices. And no, using the promise of obscene profits as the basic mechanism to finance drug development is grossly inefficient. Yes, that costs a lot of money, but it would be cheaper for the government to finance the research directly, which would direct the research in the most socially beneficial, as opposed to the most profitable direction; and then buy the drugs cheaply, instead of having most of the money go to profits, executive salaries, and marketing costs.

In other words, we can't get there by mucking around on the edges. We need fundamental reform.

We need universal, comprehensive, single payer national health care. Nothing else. That's what we need.