DAVID BROOKS had an op-ed in the New York Times yesterday that proclaimed the near impossibility of restraining costs in health care through centralised government efficiency evaluations, which is being justly ridiculed by people (Jon Chait, Jonathan Cohn, Ezra Klein) who note that every single one of the world's centralised government-regulated health-care systems is far cheaper than America's relatively decentralised private-sector one. Mr Brooks has surely had this explained to him a thousand times by now, and his failure to process the fact or incorporate it into his worldview seems to me most likely to reflect an absence of the ideological furniture on which the fact could sit. Mr Brooks doesn't seem to have an instinctive understanding of how it can be possible for unregulated free-market health-care systems to cost more and deliver inferior care than strongly regulated systems with heavy government involvement, and that's why, while he occasionally must have to acknowledge the existence of the French health-care system, he can't seem to retain it.

Here's one example among a million. The other day I went to the IPO announcement of a company that does some fairly state-of-the-art medical stuff. The company was spun off from a public institute a few years back to exploit this technology, but it's been unable to establish significant revenue or market share, or to get within shouting distance of breaking even. Meanwhile, competitors with similar technologies have gobbled up most of the market share, and one is already quite profitable. The company said it planned to raise some tens of millions of dollars with the share issue, many times its current annual expenditures and about a third of its overall market cap. And what would it do with this money? It was going to use half of it to finance a marketing drive, targeting key decisionmakers at American health-care providers and health insurers, and doctors.

Why hadn't this company been able to generate significant revenues? Were its technologies inferior? No, said an independent molecular biologist I talked to. Its product was certainly as good as the competition's. Moreover, it had actually gone to the trouble of getting its technology approved by the FDA, which the competition hadn't. (In this sub-sector FDA approval isn't yet mandatory.) But it hadn't marketed itself well. It hadn't established the relationships with providers and insurers that would ensure that its product was the one they selected. Doing so would require a marketing budget of tens of millions of dollars, in a sub-sector where the entire annual market is a few hundred million dollars.

Just think about this for a minute. A medical technology company is going public to generate the money it needs to advertise its products to hospital directors and insurance-company reimbursement officers. This entails significant extra expenditures for marketing, the new stocks issued to fund the marketing will ultimately have to pay dividends, banks will have to be paid to supervise the IPO that was needed to generate the funds to finance the marketing campaign (presumably charging the industry-cartel standard 7%)...and all this will have to be paid for by driving up the price the company charges to deliver its technologies. But beyond the added expense, why would anyone think that a system in which marketing plays such a large role is likely to be more effective, to lead to better treatment, than the kind of process of expert review that governs grant awards at NIH or publishing decisions at peer-reviewed journals? Why do we think that a system in which ads for Claritin are all over the subways will generate better overall health results than one where a national review board determines whether Claritin delivers treatment outcomes for some populations sufficiently superior to justify its added expense over similar generics? What do we expect from a system in which, as ProPublica reports today, body imaging companies hire telemarketers to sell random people CT scans over the phone?

Matthew Yglesias takes the right tack by comparing the medical industry to the shoe industry, where we all agree that the private sector produces far better shoes at far lower cost than could be produced by a state-owned manufacturer. I think the analogy is also helpful when we add in the dimension of marketing. Beyond a certain point, you can't explain the value of a great pair of shoes in any rational fashion. The reason a pair of Air Jordans was vastly superior to a pair of nondescript Soviet sneakers in 1989 was only partly that they were more durable, or had better support and traction. Most of the added value wasn't there. It was in the interplay of marketing and fashion. The satisfaction customers derive from marketing and fashion is absolutely real; in the case of shoes, it's practically the whole point. But in the case of medicine, it usually shouldn't have any place in decisionmaking. We shouldn't be aiming to make Americans happy by marketing medically useless knee surgery to them and then letting them walk down the street feeling all fine and dandy with snazzy new knees that aren't actually any better than the old ones. Not in the publically insured sector, anyway. Medically unnecessary cosmetic surgery is fine, but not on the taxpayer's dime.

The other key thing to pay attention to is who this marketing campaign was targeted at: key decisionmakers at providers and insurance companies. Those are the people who decide whether medical procedures get ordered. It's not patients. Patients aren't going to experience a loss of freedom or satisfaction because an expert reviewer at the Independant Payment Advisory Board makes the call as to whether a procedure is medically beneficial, rather than the corresponding bureaucrat at their insurance provider or at the for-profit clinic they're attending. Health care is different from buying shoes. Which is why it wouldn't be at all surprising if a board of 15 experts could play a major role in reducing expenses and improving care outcomes in the American medical industry. That's what corresponding boards of experts in France, Germany, Britain, Canada, the Netherlands and so on do, which is why their health-care systems cost half what ours does, cover everyone in their countries, and generally provide better care.