EDMUND BURKEWhether we like it or not, we all are going to have to learn quite a bit about the health care system. For most of us, this won’t be fun. The health care system is a briar patch of complexity – a subject most of us would rather not jump deeply into.
But we can’t avoid it. The nation is not going to be healthy – physically or fiscally – until we improve the system. And because the politics of improving the system are so difficult, improvements will not happen until a large segment of the public understands the problems and demands specific reforms. Improvements require overcoming resistance by special interests – insurance companies, hospitals, and doctors – and that won’t occur without something of a mass movement. We can’t leave this up to the experts.
Let’s start with our physical health. Our health care system not as good as we’re led to believe. By every objective measure, we are worse off than comparable nations. The Commonwealth Fund conducted a comparative study about the quality of care in wealthy nations. Quality was defined by the survival rates of people with potentially fatal but treatable diseases. How did the U.S. rate? Right near the bottom – number 17 out of 19 countries – behind Greece and well behind Spain. Other evaluations yield similarly dismal results. The World Health Organization evaluated the health care systems of all 191 United Nation member states. In terms of how long the average person can be expected to live without serious disease or disability, the United States rated number 24. In terms of “overall performance” of the health care system, the U.S. ranked number 37.
The fiscal picture is even worse, much worse. We have, by far, the most expensive health care system in the world. That’s unfortunate, but here’s the real problem: Like the monster in the old horror movie “The Blob,” our health care costs are growing, and growing, and growing.
In 1970, health care consumed 7 percent of our GDP. By 1980, it was 9.3 percent. By 1990, it was 11.9 percent. As of last year, it was 17.7 percent. Without radical reforms, health care costs will devour us completely.
Reforms are possible. For example, 20 percent of premium dollars paid to private health insurance companies are consumed by “administration,” that is, the cost of operating those companies. In France, which also has a private system – that is, insurance companies and hospitals are privately owned and operated, and physicians are in private practice – less than 5 percent of insurance premiums are consumed by administrative costs of the insurance companies. France accomplishes this by rigorously regulating insurance companies: insurers aren't permitted to spend money on marketing; they don't spend money on patient selection and coverage issues because they are required to cover anyone who wishes to enroll and pay for all mandated services; and what they pay for services is set by the Health Ministry. This also results in corresponding savings on the delivery side. Hospitals need far less staff to submit claims to to insurance companies; in fact, French hospitals have more doctors and nurses per patient but only a third as many administrative personnel as U.S. hospitals. Doctors, too, are largely free from the hassle of dealing with insurance companies, and can focus exclusively on practicing medicine.
For those willing to jump into the briar patch, let me recommend two superb books that nicely complement each other.
In Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform (Yale 2011), Paul Starr describes health reform efforts from Truman to Obama. Starr was intimately involved in the Clinton proposal, and he provides something of an inside account of those struggles. Paul Starr is a sociologist at Princeton who won both the Pulitzer and Bancroft prizes for The Social Transformation of American Medicine (Basic Books 1984). He is also a founder and editor of The American Prospect. (Full disclosure: From time to time, I write for the The American Prospect and work with Paul, who is in charge of book reviews.) Any reader will learn a great deal about health care policy – and even more about health care politics – from Starr’s serious but eminently readable book.
Another terrific book is T. R. Reid’s The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (Penguin Books 2009, expanded 2010). Reid describes the health care systems of France, Germany, Japan, Britain, and Canada, and a bit about Taiwan too. Reid’s a correspondent for the Washington Post, and he successfully brings a good journalist’s breezy style to complex material. Obviously, America shouldn't import another system lock stock and barrel. We need our own system tailored for our own values. But there is a great deal to be learned about what’s working – and not working – elsewhere. Anyone reading Reid’s book will often find himself asking, Why aren't we doing that here? Starr’s book answers those questions, and the reasons generally involve money and politics.