Joe Drymala, the chief speechwriter who received the e-mail, resigned in protest. `I refused to believe it because I didn't want to,' he said. `To believe that was to believe that Howard Dean was a fraud.'"

I never thought about it this way before, but today I realized that part of the reason health care costs are high in the U.S. is that insurers and doctors both have an incentive to raise them, and these two parties can collude against the others (government, pharma, employers, consumers).

Doctors obviously have a direct incentive to raise rates -- higher rates = more income. Insurers would seem to have an incentive to keep rates low, but if insurance overhead and "reasonable profit" are calculated as a fraction of rates, then insurers are basically getting a commission on their payments to doctors. So insurers have an incentive to pay more, because they then earn more.

It's not a perfect alliance -- HMO's, for example, are where the insurers stab doctors in the back -- but it helps explain high-priced procedures.