What is the most ridiculous thing about the American health care system? Is it that 45 million Americans don’t have health insurance? That is the most embarrassing thing, but it’s not beyond all rational explanation. It’s a failure of empathy. We – the majority of Americans who are lucky enough to be covered – apparently don’t care enough to do something about the minority who aren’t.

It is pretty ridiculous that we spend twice as much per person on health care as citizens of other advanced countries – the usual example is Canadians, because they are so nearby and so annoying about it – yet we are less healthy, by standards such as longevity. But this isn’t as mysterious as it seems. Dollars spent on basic care for all, or on public health issues such as the environment, usually have a higher payoff in terms of these aggregate statistics than dollars spent on vast high-tech efforts on behalf of individual sick people.

The deal every health care reformer longs to make, in one form or another, is: Stop spending so much on really sick people – especially when they’re at “the end of life” (an ominously self-fulfilling turn of phrase) – and shift the money to where it will have a bigger payoff. Perhaps hypocritically, as a beneficiary of high-tech medicine, I prefer to think of these as two separate issues. Why must the cost of universal coverage be financed by denying luckier folks (luckier in a way, that is – less lucky in another way) the treatment they need to stay alive and functioning?

Unfortunately, that is a bit too easy. There is a real moral dilemma here about what happens after you have defined and achieved the goal of decent care for everybody. In fact, this issue more than anything is what tripped up Hillary Clinton back in the early ’90s. Her health care reform plan purposely made it difficult – not impossible, but difficult – for people to go outside the system to get a higher standard of care. The reason is obvious: If a superior level of care is available, the care being guaranteed to everybody is inferior. In other words, you are rationing – denying people useful, if not vital, health care to save money. Worse, you are letting people buy their way out of the rationing if they can afford it – the way affluent young men were allowed to buy their way out of the Civil War draft.

At the moment we don’t guarantee anyone any level of health care, so this moral dilemma can be saved for another day. And in the end, the answer will have to be that of course the standard of care the government promises everybody will not be based on the principle of “money is no object” and of course people will be allowed to do better for themselves if they wish. What sense would there be in telling people that they can spend their money on anything they want except their own health?

But what is most ridiculous about the current American health care system is that we have no idea, very often, whether even the most expensive treatments do any good. Business Week had a cover story last month touting what is called “evidence-based” medicine: that is, basing treatments on whether they work. You might say, “As opposed to what?” The article has some tendentious, newsmagazinish statistics about how most medical treatments (two-thirds? three-quarters?) are based on hunch or habit or a doctor’s finances or anything except solid evidence that they actually are good for patients.

Last month, Dartmouth Medical School produced another in its series of reports about the huge variations (it usually seems to be about a factor of three) among regions of the country, or even among hospitals in the same city, in the bills for patients with the same diagnosis and similar outcomes. There are hospitals, it seems, where you walk in with a cough and walk out with someone else’s heart, and others where you walk in with a gaping chest wound and walk out with a Band-Aid. And darned if it seems to make any difference in your overall health.

This is a bit suspicious. It would be awfully convenient if it turned out that a couple of aspirin and a Cherry Coke were as effective against cancer as years of chemotherapy. I suspect that in many cases the vastly cheaper alternative is almost but not quite as good – which makes it the right answer if your concern is bang for the buck, but not if you want the biggest bang and never mind the bucks.

But why, in so many situations, do we not even know the answer? To really know it by scientific standards would require a controlled experiment, which is often impractical and/or immoral when the subjects are human beings. But if you can’t study 10 or 15 people under laboratory conditions, studying 300 million people in real life could be almost as good.

The medical records of the U.S. population are a gold mine of information about the effect of every conceivable therapy on every conceivable ailment under almost any conceivable circumstance. Or they would be, if they were brought together. But for the most part they rest in lonely filing cabinets – on paper, not digitized – hoarding secrets that really could improve our health and our finances at the same time.

Starting to gather these data was one of the most demagogued proposals in the Hillary health reform package. Republicans raised the specter of Big Brother knowing your most intimate secrets. The plan’s supporters emphasized the safeguards against misuse of the data – but when you’re talking safeguards, you’re already on the defensive.

Until recently I would have dismissed any concern about the government’s misusing your health records as farfetched. But now that we know about the current administration’s adventures with the phone companies and the Internet providers, I think those ancient Republicans might have had a point. It’s unfortunate, though, if we have to protect our privacy at the cost of our health.