Even with all that money, Warren Buffett’s donation of billions was a two- or maybe a two-and-a-half-day story. To give him his due, “the world’s second-richest man” spared us the creation of another plutocratic dynasty by giving his money to Bill Gates’s foundation instead of to his children.

Considering all the other awful things Buffett might have done with his dough, he may merit at least half of the laudatory sloberation lavished upon him on the tube and in print. He is a decent man, a clever man at making money, but about all that can be said of how he is disposing of his billions is that his choice was safe, insipid and probably inconsequential in the long run.

The money-to-impact ratio of most of these mega-foundations is low. One would be hard-pressed to name any single accomplishment that can be honestly credited to the MacArthur Foundation or the Ford Foundation, although the list of laudatory causes each has funded would stretch from Philadelphia to Las Vegas.

Increasingly, foundations are noteworthy for their high salaries, their princely accommodations, their perks, their mediocre staffs and their tendency to pass money out to their friends. There are days when it seems that the only effective foundations are those underwriting right-wing think tanks whose twofold purpose is to crank out propaganda and launder money by paying off politicians in the form of vacations and jobs.

Foundations also serve as a quiet form of social control, either by buttressing status quo organizations and/or schools of thought or by buying off possible troublemakers. Perhaps this is one task they are reasonably good at, because America is suffering from a dearth of troublemakers. They are either being bought off or we cannot produce them anymore.

The Bill & Melinda Gates Foundation, to which Buffett has pledged to give his many billions, is already deeply committed to finding cures for diseases. Some question exists as to how badly medical research needs this influx of money. Things have changed in the century since John D. Rockefeller put money into the eradication of diseases like hookworm and yellow fever. That was a time when government put almost no money into medical research, there were no international health organizations and the pharmaceutical corporate giants, with their huge research budgets, did not exist. Rockefeller’s money filled a real gap; the Gates/Buffett money far less so.

What this use of money lacks in imagination, it makes up for in safety. Pick an innocuous but indisputably worthy project and start pouring in the money and pouring out the press releases. Do it long enough and one President or another will pin a Medal of Freedom on your chest, and the volume of adulatory if simple-minded praise will grow to ear-splitting levels. It may not always be true, but generally the safer the project, the more inconsequential the results.

It would take the kind of cojones that neither Bill Gates nor Warren Buffett have shown they have, successful as they have been, to do something about American health more important than paying for the discovery of a new drug. That something would be the dismantling and reorganization of the increasingly dysfunctional and ineffective American health apparatus.

According to the Economist magazine’s “World in Figures,” life expectancy in the United States is a little less than 78 years, equal to that of Portugal and shorter than every nation in Europe except Denmark, not to mention Japan and, if you can believe it, Castro’s Cuba. You can expect to live more than a year and a half longer in Cuba than in the United States.

Whether that figure includes the people languishing in Castro’s dungeons I cannot say, but what the figures do show is that more money is spent on health for less results in America than in any other place in the world. In Canada–where, Americans are told, the socialized medical system does not work–you can expect to live about three years longer than in the United States. Almost the same in France, a country Americans are taught to treat with contempt because of its blundering statist ways.

In France and in the scores of other countries where people live longer, there are more doctors per 1,000 people than here, and in all of those countries less money is spent on health and medicine. As a percentage of gross domestic product the United States spends a third or more than the nations where there is a significantly longer life expectancy.

The reason for these disparities is that the health system in the United States is busted. That is where Gates and Buffett might have come in had they had the onions to use their money to redesign the system and generate the political force to put the design into effect.

Such an undertaking would have pitted the Gates/Buffett-financed forces against the insurance companies, the nursing home chains, the hospital cartels and the drug monopolies. Success would have meant that in any given year, ten times the Buffett fortune would have been rescued from the health racketeers and redirected to prolonging life and happiness in the United States.

Whether in Africa or Chillicothe, Ohio, a drug or treatment is useless if the institutional arrangements do not exist to get it to the patient in a timely and humane fashion. Currently, such arrangements do not exist at all in many parts of Africa and exist in the United States in only a dwarfed and defective form.

The Gates/Buffett money might have been used to change all that. It would have been a hell of a battle, and even with so much dough backing up the good guys, the cause might still have been lost. We will never know. Billionaires are not known for risking unpopularity, and foundations, lost in the seminars and discussion groups of their own funding, do not pick fights.