Alone among industrialized nations, the US lacks a national health insurance system. Forty million Americans lack any form of health insurance, many more face losing their job-linked coverage in company layoffs.
Meanwhile, US annual spending for health care totals US$4,600 per capita, more than twice the average of other industrial countries. Health care expenditure totals a world-leading 14 percent of GDP stands, for a grand total of US$1.3 trillion -- and rising.
According to the Organization for Economic Cooperation and Development (OECD), despite this colossal spending, America lags behind Japan and several European countries in standard measures of health: infant mortality, life expectancy at birth, and deaths that could have been prevented by appropriate medical care. The US spends more and gets less and all indications suggest that the perverse economics of American health care will continue more or less unchanged indefinitely.
ILLUSTATION: MOUNTAIN PEOPLE
The reason is that the losers in this system tend to be poor, politically unorganized and inarticulate, while their more fortunate fellow citizens are insured for the costs of treatment and reap the benefits of the high-tech excellence for which American medicine is renowned.
Starting with the president, continuing through the ranks of Congress and the federal bureaucracy, and extending to the nation's many millions of steadily, safely employed executives and workers, ample health insurance is a guaranteed benefit. Also safely insured, under the federal Medicare program, are 40 million elderly and disabled citizens.
From their personal experi-ence, the system works well. The big bills incurred by expensive diagnostics and hospital stays are covered in large part or altogether. For the well insured, money is not a barrier to good care.
The poor receive some coverage under the sparsely funded Medicaid program, jointly funded by Washington and the individual states. The not-so-poor population exists in a medical no-man's land, ineligible for public assistance but lacking the money to pay big bills.
Many of the 40 million without insurance are employed, but at low-wage jobs and by companies that do not provide health insurance as a benefit. Some of the poor do manage to piece together the price of care, but the difficulties of doing so are becoming greater due to medical inflation, currently running at over twice the general rate of consumer inflation.
Costs are being pushed higher by the arrival of new medical technologies, aggressive marketing of pharmaceuticals directly to consumers and the public's high hopes for medical miracles. Many expensive treatments are beneficial. But many, although dubious or altogether worthless, easily become established in medical practice and produce a torrent of income for persuasive doctors serving well-insured patients.
For example, surgery for arthritis of the knee fetches some US$3 billion a year for doctors, but, according to a study conducted by the US Department of Veterans Affairs, it is therapeutically useless. Studies such as this are rare, because the doctors who profit from the practices being investigated do not welcome independent reviews that might demolish their trade.
The federal Agency for Healthcare Research and Quality, responsible for assessing the efficacy of medical treatments, has led a precarious existence under the gaze, and political contributions, of medical specialists.
Attempts to bring economic rationality and equity to American medicine date back to immediately after World War II, when then president Harry Truman's proposal for establishing a national health insurance system brought cries of "socialized medicine" and quick defeat in Congress.
The late president Richard Nixon instituted price controls to hold down soaring medical costs, but when the controls were lifted, prices took off. The most determined effort to remake the system arrived with the Clinton administration's proposal for a comprehensive national health insurance system jointly financed by employers and the federal government. Once again, the health-care sector, fearing a loss of money and autonomy, mobilized determined opposition.
Ineptly presented to the public, the Clinton plan died in Congress. Into the ensuing vacuum came managed care, which was designed to hold down health-care spending by controlling access to treatment. So "incrementalism" -- a small fix here and there -- became the basic strategy of health-care reform, leading, for example, to programs to provide care for poor children and a current proposal to help the needy pay for drugs. Costs were contained, but not so the outcries of aggrieved patients who felt they were denied adequate care and the late-night comics who conjured up scenarios of "drive-by" obstetrics and other pointed jokes.
According to the latest estimates, health-insurance premiums will rise this year by 10-15 percent, following similar increases in recent years. Corporate employers have responded by requiring employees to pay part of the insurance costs -- which is, in effect, a pay cut. But this has done nothing to address the underlying problem -- the continuing rapid rise in the cost of health care.
Will America eventually emulate the rest of the industrialized world and provide health insurance for all?
Maybe, but not soon. In the words of a renowned health economist, Victor Fuchs of Stanford University, "National health insurance will probably come to the US after a major change in the political climate, the kind of change that often accompanies a war, a depression, or large-scale civil unrest."
Daniel S. Greenberg is the author of Science, Money, and Politics: Political Triumph and Ethical Erosion.
Copyright: Project Syndicate
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