High and rising prices are the most obvious problem. Americans pay much higher prices for specific services than those in other countries. Obscene price increases for selected drugs are familiar: think $600EpiPens and the Turing Pharmaceutical decision to raise Daraprim from $13.50 to $750 a tablet.

But the problem is more general: Among 54 prescription drugs commonly used by older Americans, Medicare pays nearly twice as much per dose as do the government systems in Canada, England and Norway. That's why the President wants to bring our drug prices "way down."

And the price problem extends well beyond drugs: Open heart surgery is 70% more than the next highest country; an appendectomy over two times more. And the price for a day in the hospital is about five times more in the US than other developed countries.

Why are prices so high? An important part is administrative costs: our complicated insurance system requires an army of billing clerks -- employed by hospitals and physicians on one side and private insurance companies on the other. Another is that we use more technology (tests, devices) and labor (nurses) to deliver a "visit" or provide a hospital stay. Plus, some providers simply charge more for a service because they can get away with it.

If lower prices were all that was needed, increased competition might be a plausible solution. But market forces cause medical care to expand: both to provide more services to patients and to produce more patients to serve. While some of this increased volume may be beneficial, much of it produces more mixed effects -- and some is outright harmful.

Excess volume is most relevant at the extremes of medical care: care for the dying and care for those who are well.

There is excessive medical care at the end of life. Most Americans want to die peacefully at home. But most die with a costly hospitalization at the end of life -- one that often involves painful procedures and interventions.

Most Americans want to preserve resources to pass on to their children. But many will die after an extended stay in a long-term care facility -- one that can involve shuttling back and forth from the hospital. Pneumonia used to be considered a friend of the elderly, now it's just another problem to fix. Maybe such efforts lengthen life, but whether they improve quality of life is much more debatable. They certainly work to impoverish our children.

There is also excess at the other extreme: medical care for the well. In the past, people sought medical care because they were sick. Now we encourage people to be evaluated to make sure nothing is wrong.