If energy costs spiral up, then 5,000 mile flights might become prohibitive, at which point alternatives based in Mexico or Central America become attractive from a cost basis. I have covered the emergence of cash-only dental clinics in Mexico designed to serve American customers, so the precedent is already firmly in place.

As Americans, we believe it is our birthright to avoid hard choices; we deserve to "have it all": super-costly medical care, new infrastructure, a new energy complex, the best military forces, etc. without any trade-off required. Our various trading partners have enabled this fantasy by funding our trillions in new debt/ Federal deficit spending. Should that gravy-train ever grind to a halt, and we are unable to borrow another couple trillion a year to fund "everything we want and need and care about," then we will collectively have to start making the difficult trade-offs.

Perhaps we will then finally get serious about demanding some basic efficiencies in these vast, sprawling industries.

It's hard not to look at the Pentagon (which is basically viewed as a jobs/pork program by Congress) and the healthcare complex and speculate that waste and inefficiency is the result of being protected from foreign competition. The same could be said of the entire education complex in the U.S., another "protected" domestic industry with costs that rise 6% or more a year even as the underlying economy grows at about a third of that rate.

If we look at these growth rates in cost structure, we discern unsustainable trends. It is tempting to hope that tinkering with the edges can "fix" the problems--easier student loans, higher co-pays, etc.

But none of these tinkering schemes address the core issue, which is the structural costs cannot be controlled without systemic transformation of the entire models of healthcare, Armed Forces and education. Competition provides the leverage which "consensual political reform" cannot, because no one will allow their sacred cows to be slaughtered for the common good.

There is one final structural dilemma embedded in the healthcare complex. By some measures (for instance, chronic diseases), our collective health has declined even as our spending has skyrocketed, and this forces us to ask why this is so.

Certainly one answer is the combination of lax marketing regulations, profit motive and Madison Avenue persuasion which together have created a toxic brew of questionable drugs being hyped and fear-mongered to a credulous frightened public and an overworked cadre of health providers.

Another is the very ambiguity of so many procedures, tests and drugs. If we spend $1 trillion on new power lines and solar-power arrays, regardless of what choices were made (perhaps not the best systems, perhaps politically influenced decision-making, etc.), at the conclusion we have new, measurable infrastructure in place which we can deploy to generate electrical power.

If we spend $1 trillion on more tests, procedures and drugs, the actual measurable improvement in health is at best ambiguous and at worst near-zero. Via Medicare we pay for drugs which my parents faithfully consume which may or may not even work. For instance, statins appear to be essentially useless; blood-pressure reduction drugs don't seem to lower heart attack rates, and so on.

Toss in needless hospital visits (hey, Medicare is paying, you better follow our orders and consent to being hospitalized at $30K a day) and the resulting infections/ deaths, botched operations, needless procedures, redundant/needless tests and we have to conclude that it is entirely likely we got very little improved health for that $1 trillion investment--much of which is borrowed, and hence once interest is added in, it's actually $1.5 trillion.

This is not to say some lives won't be saved or extended by the $1 trillion, it is only to point out the inherent ambiguity in measuring the results. If the patients didn't consume the 7 drugs a day, didn't go in the hospital, didn't get the 3 extra tests, didn't consent to the operation--would they actually be healthier? There is no way to know.

One obvious idea is to set up a triage which funds those medical procedures and drugs which we know work for specific conditions like infections, injuries, removal of tumors, etc. Beyond that, patients are instructed to first do whatever lifestyle changes may improve their condition; beyond that, whatever cheap generic drugs might help are paid for, and beyond that, it's on the patient's dime.

While we can borrow $1 trillion a year to put off any trade-offs, it's nice to "debate" whether this would "work." But when we can no longer pay for our "must-haves" with borrowed trillions, then we'll have to make the hard choices anyway.

It seems wise to start thinking about the fairest, most efficient forms of financial and healthcare triage now, before insolvency forces our hand.