Still the Best Healthcare in the World
A pregnant American arrives at her doctor’s office. It’s time for her ultrasound check. The doctor wheels over the machine from the corner of the room: of course he has his own.
A child has a fall from a slide. There’s blood in his urine. The parents race him to the emergency room. Two hours later, the boy’s having a CAT scan. (An American is twice as likely to use a CT machine in any given year as a Canadian, four times as likely as a Briton, and seven times as likely as a Dane.) A car driven by an illegal immigrant smashes into a tree. The driver and his family are horribly injured. They are raced to the nearest emergency room and treated, no questions asked, no bill presented.
That’s American healthcare at its best. America at its worst, of course, you know. Or do you?
Europeans see the American health system as a brutal Darwinian struggle. The poor are abandoned, the sick must produce credit cards at hospital emergency rooms and government disavows responsibility for the health of the population.
But those are largely imaginary or exaggerated ailments. The hardest problems for Americans are not so much medical as financial. Insurance premiums have doubled in the past decade and Medicare and Medicaid, the government health programs, are growing at a rate that cannot possibly continue. Tens of millions of people lack insurance. Yet they do not go uncared for. Rather they use the most expensive care, emergency care, and hospitals add the cost on to the bills of paying patients.
Almost all the problems of the US health system trace back to a pair of unexpected ironies: profit-driven private insurance corporations find it much harder to say “no” than governments do, and American governments are more unsustainably generous than their European and Canadian counterparts.
That sounds incredible, I know. But consider: government looms huge in the US health system. An absolute majority of all health dollars spent in America are spent by one form of government or another. Everybody knows that the US has a private health system while neighboring Canada’s is public. Yet US federal and state governments spend as much public money on healthcare per American as Canadian federal and provincial governments spend per Canadian.
For all practical purposes, healthcare is just as much a right in the US as it is in Europe. Since 1986, federal law has required all hospitals that receive federal money (ie, just about all of them) to provide emergency care to any patient who presents himself or herself. Many states back this federal law with even stronger laws of their own.
Government generosity drives private health costs higher and higher. Health insurance is regulated by state governments. Each government decides what local insurers must cover and how they may cover it. Fifteen of the 50 states require insurers to cover fertility treatments. Twenty-four states require coverage of eating disorders. Thirty-five states require coverage of reconstructive surgery after a mastectomy. New York state requires insurers to charge the same rate for all customers, regardless of health conditions, while 11 other states tightly restrict the ability to charge more for more sick patients.
Despite the rhetoric, Republican administrations expand government coverage just as much as their Democratic counterparts do. George W. Bush’s Administration, for example, created one huge new healthcare program (prescription drug coverage for the elderly) and greatly expanded another (the State Children’s Health Insurance Program, which now covers under-18s whose parents earn up to 250 per cent of the poverty level).
Again despite the rhetoric, Democratic administrations fret as much about healthcare costs, perhaps even more, than Republicans. Because of the Clinton Administration’s fierce promotion of health maintenance organisations — the much-hated but super-economical insurance plans — healthcare costs grew more slowly in the 1990s than in the decades before and after. Barack Obama has publicly mused about the need to spend less on the elderly in their final years. Here he is speaking to The New York Times in April, a comment that puts some credibility in those fears of “death panels”:
The President: “The chronically ill and those toward the end of their lives are accounting for potentially 80 per cent of the total healthcare bill out here.”
Interviewer: “So how do you — how do we — deal with it?”
The President: “Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance.”
The raucous protesters at the town hall are not defending the liberty of the individual; they are defending the status quo, a status quo that for many means lavish government healthcare for the elderly. They (rightly) fear that government is much more concerned to hold costs down than to improve care.
Objective studies find little difference in outcomes between America’s costly care and the much cheaper care in more statist systems. Canadians live longer, the Dutch have better infant mortality statistics, etc. Healthcare systems do not make much difference to health outcomes. Americans are more likely to be obese than Europeans. (One health dollar in ten is attributable to the obesity-caused type 2 diabetes.) Americans shoot each other, and give birth prematurely, more often. Healthcare can do only so much to compensate for these choices (and a severely underweight baby is more likely to survive in the US than just about anywhere on Earth).
What the US system offers to those who enjoy good coverage is much harder to measure: convenience, security, responsiveness to patients and personal attention from doctors who compete to attract customers.
Fear of the loss of American medicine at its best is what is riling the town halls. Americans like what they have. They worry that it cannot continue. And they correctly surmise that a President with other spending priorities seeks to take it away.
Originally published August 14, 2009 in The Times.