During the campaign there was a lot of rhetoric on health care, but neither side discussed the real problems, issues or solutions. The problem is not that 45 million people have no health insurance. The problem is that for those who do have health insurance, it is like paying on a second mortgage.

The problem is that medical care costs have spiraled out of control and the political debate has been simply a matter of how government could defray the cost. That is, there has been no attempt to address what is driving the costs inordinately high.

Issues are Complex. Just as the real issues cannot be covered in slogans or sound bites, a comprehensive discussion is not possible in a single column article. Comprehensive discussions are available as entire chapters in the book this column profiles. However, as a brief overview there are four basic issues. The first is the threat of frivolous litigation, which automatically adds 10 to as much as 30% to the cost of medical services. To date our politicians have not made a good faith effort to deal with this issue.

For the most part, the Republicans have tried to limit awards or exempt specific industries from lawsuits. The Democrats, being primarily comprised of lawyers, have not cared to make any changes whatsoever.

The fundamental problem is that perjury statutes are not enforced in civil cases. This has allowed a disgraceful situation to occur in which a cadre of doctors, engineers, chemists, etc. have evolved into professional witnesses. "Professionals" who make their living by skewing testimony for either a large fee, or in some cases a percentage of the award!

Another problem is the culture of our medical system that does not consider the disparate competence between doctors, but instead places all physicians in authoritarian roles. A particularly outrageous manifestation of this concept is the fact that a "prescription" is often required to obtain simple laboratory analysis!

Consolidation in the hospital industry has led to many hospitals having an oligopoly and sometimes even monopolistic pricing powers within specific markets. Beyond that, unethical billing procedures have become an accepted practice. Evidence of this are Medicare audits where billing includes unnecessary or even procedures never performed. Cash patients are typically billed much higher fees than Medicare or insured patients (since no one will review the bill).

Because of the authoritarian culture within our medical system, patients do not "shop around" for reasonably priced services. This in turn feeds those within the industry with a propensity to overcharge.

There is ample opportunity to obtain both lower cost services and insurance. Domestically there are independent laboratories that typically charge a fraction of what is the norm for hospital laboratories. Physicians in private practice likewise will be much less expensive than physicians aligned with hospitals. Becoming an educated medical care shopper can save 30 to 60% for most services.