The one constant in the current healthcare debate is the heated and generalized rhetoric. Conversations typically devolve into non-substantive posturing, and everybody gets rolled up: if you favor public sector involvement, you’re a "socialist"; if you don’t, you have no concern for sick people. I don't believe either of those fallacies, because in truth, they're intellectually lazy – a decision to trade details for bumper-sticker slogans.
For people like me, who see universal coverage as a moral and economic imperative, and who think nuance, detail, and pragmatics matter, T. R. Reid’s "the Healing of America" is required reading, imo. In analyzing the different health systems of the world, Reid digs below the rhetoric and into the substance. In the process, he obliterates common myths held by Americans about other delivery systems, while also showing that all models carry unique problems. The big takeaway is that the U.S. should learn from this reality and adopt an approach that’s consistent with our needs.
First off, on core metrics, it's simply not accurate to claim the U.S. has the best healthcare system in the world. We certainly employ some of the best doctors, but delivery fails on many levels:
• It’s estimated that 22,000 Americans die each year from treatable illness because they can’t obtain insurance coverage (see note appendix for a real-world example).
• According to Harvard and the WHO, the United States ranks 37th overall in quality, just behind Costa Rica, and just ahead of Cuba. This means that on measures like infant mortality, life expectancy, and preventing death caused by treatable disease, the richest country in the world falls way, way short.
• Even with the gaps, we spend more than anybody in the world on healthcare, both as a percentage of GDP (15-17%) and in per capita terms.
Working from this baseline, Reid toured the world to find out why. He discovered that there are four basic models, and contrary to the common perception among Americans, very few of them in practice are true "socialist" frameworks (where the government owns and operates industry). In most advanced nations, doctors and insurers are private (though in many cases they are regulated like public utilities, subject to statutory price controls). Within these systems, vibrant competition takes place, as providers fight for patient volume and loyalty.
Here’s a brief description of each model:
- Bismarck: Doctors and insurers are private, and premiums are shared between employers and employees. Japan, Germany and France embrace this model, as do we (roughly). The difference is that in the former countries, insurance companies are largely non-profit, and they're regulated much the way utilities are in the U.S.
- Beveridge: Almost all healthcare providers work directly for the government. Hospitals and outlets are also state-owned. This is probably what most Americans think of when talk of "socialism" enters the fray. Interestingly though, it's exactly how veteran healthcare is managed in the U.S., which scores very highly in satisfaction surveys. Great Britain relies on this approach.
- National Health Insurance: Doctors are private, but payouts are managed via government-run insurance; the system is typically funded through general tax collection. Canada's single-payer system is a good example here. But our Medicare program mimics it in several ways.
- Pay for Service: There is no system. People who can afford healthcare on their own receive it, and those who can't go without. The poorest countries typically follow this "model."
So it’s clear there’s a lot of variety out there, and the blanket "socialist" label neglects the fact that typical systems include a mix of public and private entities. Further, we shouldn’t arrogantly assume that nothing works in other countries; the truth is that other industrialized systems cover everybody for much less than we spend, and their populations are healthier overall as a result. That doesn’t mean the U.S. should emulate entire frameworks -- it’s more that we should learn about what works, and make smart decisions here with that knowledge.
For instance, we spend 30 for 40% on healthcare administration, while France and Taiwan keep it near 5%, largely through standardized electronic record-keeping and "smart" cards that centralize patient history. Why wouldn't we want to mimic that (assuming privacy is protected)? Great Britain religiously focuses on prevention to keep costs down. Why shouldn't we create a public option based on the "medical home" model to do the same (rewarding quality, not quantity and churn)? If it works -- there are already smaller-scale success stories in the U.S. -- Medicare will also adopt it, generating massive cost savings. And private insurers might follow suit as well.
[As an aside, it’s also important to understand that merely offering a public option alongside current private choices is most certainly not "socialism" (state owned and operated industry), any more than having public transportation options means we live in a "socialized" system for moving around. The simple observation that millions of people buy cars from private companies renders the latter conclusion absurd prima facia.]
Having said all this, for me personally, I don't think a single-payer solution is right for the United States. In my view, we're best off leveraging the public sector to close gaps and reduce costs, a framework that supplements private innovation and works toward the creation of a unique American model. A public option like the one currently under consideration is a good fit -- it would drive down costs through an efficient fee structure and negotiating power.
But whatever one's opinion, we should all abandon the fear mongering and distortions, so a fruitful debate can arise out of all this complexity. "The Healing of America" is a great resource for that exercise.
(Appendix):
Some say that all Americans do effectively receive healthcare, because emergency rooms are required to serve them. It is true that one of the reasons healthcare is so expensive in the U.S. is that massive cost shifting takes place from the ER to those with coverage ($1000 to $2000 extra a year is tacked on to bills for the INsured). But it is not true that this care is the equivalent of being "covered." ERs are only required to serve those who are very sick (at risk of death), meaning that people typically receive free treatment only when it's too late and ridiculously expensive.
The book details the story of a woman who died from lupus. When she contracted it, she couldn't work, so she lost her job and her insurance. Left on her own, her condition was a prohibitive pre-existing condition, so she was turned down by every insurance company she pursued in the open market. Near the end of her life, she finally received ER treatment. Several unsuccessful and costly operations later, she died. For a fraction of those late-term costs, a preventive scheme would have enabled her to live a full life.