A couple of weeks ago, Michael posted a brief set of observations about the strong health care system in the Netherlands, implying a superiority over the U.S. system that is common from both domestic and foreign critics of American health care.
Since my wife’s diagnosis with breast cancer a couple of months ago, I have had frequent and intense personal exposure to the U.S. health care system. I feel this gives me the perspective to offer a few observations about its virtues and its vices, both of which tend to undermine the simplistic memes that often dominate the health care debate. I am not going to get into pointless nationalist debates about whose system is “better”, but rather I want to encourage all involved to see the inevitability of tradeoffs and the impossibility of magical solutions.
Virtues: Speed and pervasiveness of access to high quality care for the well-insured. Until this summer, I didn’t know so many different types of scans even existed, let alone that the multi-million-dollar machines that do the different kinds of CT, PET, MRI, and other scans existed each in multiple different forms within the same medium-sized city. Access to specialists was similarly dizzying, with multiple practices available for all of the many different kinds of referrals. The longest wait time was two weeks. This kind of pervasive availability results from extensive investments by competing providers and is thus not available when profit-making incentives are stripped out of a system, as in even the best nationalized, single-payer systems. There is a good reason that the wealthiest people from Canada and the U.K. wind up seeking care in the United States as their only option for avoiding stringent rationing and even outright unavailability of some high-tech tests and treatments in their own country.
Vices: Price. All the wonders I cite above is really only available to those who not only have health insurance, but who have the right health insurance. Andrew Enthoven, who Michael credits with the creation of HMOs, was in fact a RAND Corporation analyst who’s exact innovation was the infamous “co-pay” that requires individuals to share the cost of the health care they use in order to provide a disincentive to overuse. But for those with a serious medical condition, the co-pays can add up very quickly. Only those with an unusually excellent plan that has a relatively low annual cap on out-of-pocket expenses can avoid very serious impacts. And the raw cost for those without insurance can be crippling — one very partial accounting I saw for a single month’s worth of the treatment process approached US$50,000. Those who do not have access to these gold-standard health plans may find the wonders of U.S. health care just as out-of-reach as if they were in a rationed nationalized system.
What are the implications for these observations on the eternal debate over health care in the U.S.? Mostly that advocates should dispense with the illusion of easy solutions or romanticized models from other countries. Any increase in access funded by the government will either require a massive increase in costs paid or a significant decrease in availability. There is no free lunch at the cutting edge of technological health care and slogans about social justice won’t produce MRI machines to feed demand in the absence of profitability. Yet, refusal to increase access makes those wonders merely theoretical for a huge proportion of the population, probably more than two-thirds. The miracle of high-tech capitalist health care has a dark side in the neglected masses who die needlessly within sight of its unrivaled glamor.
European systems have largely chosen the option or prioritizing access to primary care over access to advanced care while the U.S. has heretofore chosen to prioritize advanced care over broadening primary care. Modifying the U.S. choice while avoiding the killing of the golden technological goose is a challenge with which no health care plan I am aware of has yet seriously grappled.
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