"Managed care is profit driven, while government care is cost driven. The point is that the outcome will be the same."

Not true.

As miguel pointed out, the privates spend something like 20-30% on overhead -- ads, underwriting -- while medicare spends 5%.

That's huge savings. We're talking big money -- something like 12% of GDP (forget the actual figure) -- so if the entire health care industry was nationalized, 15-20% savings would be an enormous sum.

Plus, privates can afford to break even. They need a profit. They need to pay dividends. They need growth. Otherwise capital will move elsewhere. That's all waste as far as I'm concerned.

And besides, your theory about the high cost of the elderly doesn't make sense. Is America any older than Europe, Japan or Canada?? I've never heard that. Yet, they have better outcomes and pay less. Whatever we are doing it is bad. And their care is more highly regulated by government than ours.

A good rule of thumb: If someone else is succeeding while you are floundering, copy them.

You are confused about a few things.

1. Those over age 65 account for about 35% of total health spending. Disproportionate, but your figure exaggerates. It's sick people (with multiple chronic conditions, especially) that account for the vast majority of costs. There is overlap--more old people are sicker--but it is the treatment of those who are unhealthy that drives cost.

2. The rising cost of health care overall has had little to do with the size of the aged population. Health care premiums for those under age 65 have been growing just as fast if not faster than for those over age 65 even as the level of spending is lower. Furthermore because of Medicare, the under 64 risk pool is not really affected byt he needs of those over 65. AETNA is not covering the medicare folks. The next 25 years will see a significant increase in the aged population, but much less so in the US than in Europe, and Japan & Korea.

3. The rising cost of health care has a great deal to do with the inefficient delivery of care at all ages. There is enormously detailed data on this fro the Medicare population from the Dartmouth Atlas project (google it). The main culprit is overuse of health care resources which is reinforced by the fee-for-service method of payment. An additional source of inefficiency is that many doctors provide care based not on evidence but what they know or are used to.

4. There are many providers who deliver care significantly more efficiently than average. They are able to do so primarily because they are integrated, provide team based organized care (an important distinction from "managed" care), and they rigorous use evidence to continually improve clinical decision making. People who are confused between "managed" care and "organized" care, or between "evidence based medicine" and "rationing" should read up on Intermountain Health Care, Mayo Clinic, Geisinger Clinic, Group Health of Puget SOund, The Billings Clinic, Dartmouth Hitchcock, Kaiser Permanente, The Marshfield Clinic, Denver Health, etc... We know how to do this right. We have lots of proof.

5. Patients are rarely empowered to make their own decisions over the care they receive and never so much so than in the end of life. By then it's too late--Many patients, fully informed and empowered to actually share in the decision making process choose less invasive treatments, fewer heroic measures that only serve to prolong their lives by days but use massive resources and destroy any sense of a dignified process of dying. Shared decision making, especially when there is evidence to guide choices results in better care, more satisfaction and very often less costly care.