As a family physician, I've tried to cut medication costs for my patients. Even if patients are only paying a portion of the costs, I've noticed that most are concerned about how expensive a medication is. I think many people realize that the health care gravy train can't last forever. As part of comprehensive health reform, I think that any government sponsored health care needs to only pay for generic medications (if available). We just cannot afford to pay for the fanciest (or sometimes even the best) med out there.
A second part of health care reform needs to judge the cost-effectiveness of any test that is paid for by big-daddy government. If it is not cost-effective (like PSA testing for prostate cancer) it is not funded. People can still get PSA testing if they want, but it won't be guaranteed. This would free up more dollars to pay for proven-beneficial tests, like mammograms for women aged 50-79.
Medical work-ups need to make sense - medically, financially, and practically. Testing guidelines that are reasonable should be paid for (checking blood sugar levels in diabetics) but over-the-top, test-for-everything-so-I-don't-get-sued testing is paid for by the patient (if they choose to get it).
Treatments need to be made available universally as we can afford it. This probably will mean that not every patient will get dialysis, the organ transplant, or elective surgery. But, we (as a country) have a budget and what we can pay for should be clear. The money we have should be used for maximal impact and benefit.
And finally, we need to introduce a little healthy capitalism to this process. Let doctors, labs, hospitals, etc. compete for the consumer dollar.
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I think you touch on a very good idea about delivery of health care within the concept of affordability. It might behoove you to consider the approach that I understand the state of Oregon has adopted: namely, Oregon considers two major factors when deciding which medical procedures to pay for. First, of course, is efficacy of the medical treatment under consideration. The second is the cost of the medical treatment. For example, if a treatment is very effective and inexpensive, then it scores high on a comparative scale of procedures. If it is effective but expensive, it scores lower. If it is ineffective and expensive, it is reimbursed. I understand that the state of Oregon than rank orders hundreds of medical treatments on these two scales (maybe also including the severity of the medical condition, life threatening vs. elective procedure). As I recall, a good example of a procedure that ranked very nearly the top was giving antibiotics to treat pneumonia. It is a life-threatening illness, antibiotics are very effective, and they are inexpensive. Thus, Oregon will pay for this service. Vaccines were also high on the list (obviously). Oregon then estimated the number of times each medical procedure would be performed during a year and how much money it coiuld spend during the year. Based on these statistics, Oregon then draws a line in the list, determining what procedures it will pay for and whish ones fall below the funding line. It seems like a good approach. The more money available, the farther down the list the government can draw the line.
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