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Our fix-it-itis is not a simple social gaffe but the evidence of a deep blind spot born with the help of the market. We are educated about illness by television commercials... A puzzle like me that cannot be solved is a point of discomfort, a disjuncture, a black hole... My body is a discomfort, a burr in the hide of the marketplace itself, a reminder that not all pain can be treated with a purchase.

Still, there was no getting around the fact that we’d be asking House Democrats to swallow a version of healthcare reform they’d previously rejected out of hand—one with no public option, a Cadillac tax the unions opposed, and a cumbersome patchwork of fifty state exchanges instead of a single national marketplace through which people could buy their insurance. “You still feeling lucky?” Phil asked me with a grin. Actually, I wasn’t. But I was feeling confident in the Speaker of the House.

Let’s say that a client has asked you to speak to a management team of 50 people. It is a successful high-tech (or health-care or automotive—it really doesn’t matter) organization in a competitive marketplace. The vice president of operations wants to instill formalized techniques that people can use to constantly raise their own standards and outpace the competition. Your speech is the kickoff for the daylong conference. All of the other speakers and activities involve internal people.

Unlike those of almost any other area we can think of, the dynamics of the medical marketplace seem to be such that the advance of technology has made medical care more expensive, not less. First, it appears to encourage more procedures and treatment by making them easier and more convenient. (This is especially true for procedures like arthroscopic surgery.) Second, there is little patient pushback against higher costs because it seems to (and often does) result in safer, better care and because the customer getting the treatment is either not going to pay for it or not going to know the price until after the fact. Beyond

If you are confused by the notion that those least able to pay are the ones singled out to pay the highest rates, welcome to the American medical marketplace. Pay

As the figure of the traditional doctor fades away, it is being replaced by a figure to the drug rep, one whose responsibility is to compete as vigorously as possible in the medical marketplace. Patients are being replaced by health-care consumers, who shop for the best medical bargains they can find.

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