For those of you in a rush, however, I offer this take from Malcolm Gladwell:
| The bigger reason is simply that I woke up one day and realized what much smarter people than me (Adam Gopnik) realized a long time ago, which is that the idea of employer-based health care is just plain stupid--and only our familiarity with it and sheer inertia prevent us from rising up in rebellion. I always try to think of a suitable analogy and fail. The closest I can come is to imagine if we had employer-based subways in New York. You could ride the subway if you had a job. But if you lost your job, you would either have to walk or pay a prohibitively expensive subway surcharge. Of course, if you lost your job you would need the subway more than ever, because you couldn't afford taxis and you would need to travel around looking for work. Right? In any case, what logical connection is there between employment and transporation? If you can answer that question, you can solve the riddle of the U.S. health care system. And maybe I'll change my mind back. |
Gladwell has an amazing ability to both synthesize and simplify information, something he's now doing through his new blog, from which the above quote was taken. If you're looking for a longer take on healthcare from Gladwell, this article from the New Yorker is an essential read. In it Gladwell simply shreds the myth of the moral hazard and health insurance, a myth on which Bush's health care solutions are almost entirely based. Here's a small sample of Gladwell's take:
| One of the great mysteries of political life in the United States is why Americans are so devoted to their health-care system. Six times in the past century--during the First World War, during the Depression, during the Truman and Johnson Administrations, in the Senate in the nineteen-seventies, and during the Clinton years--efforts have been made to introduce some kind of universal health insurance, and each time the efforts have been rejected. Instead, the United States has opted for a makeshift system of increasing complexity and dysfunction. Americans spend $5,267 per capita on health care every year, almost two and half times the industrialized world's median of $2,193; the extra spending comes to hundreds of billions of dollars a year. What does that extra spending buy us? Americans have fewer doctors per capita than most Western countries. We go to the doctor less than people in other Western countries. We get admitted to the hospital less frequently than people in other Western countries. We are less satisfied with our health care than our counterparts in other countries. American life expectancy is lower than the Western average. Childhood-immunization rates in the United States are lower than average. Infant-mortality rates are in the nineteenth percentile of industrialized nations. Doctors here perform more high-end medical procedures, such as coronary angioplasties, than in other countries, but most of the wealthier Western countries have more CT scanners than the United States does, and Switzerland, Japan, Austria, and Finland all have more MRI machines per capita. Nor is our system more efficient. The United States spends more than a thousand dollars per capita per year--or close to four hundred billion dollars--on health-care-related paperwork and administration, whereas Canada, for example, spends only about three hundred dollars per capita. And, of course, every other country in the industrialized world insures all its citizens; despite those extra hundreds of billions of dollars we spend each year, we leave forty-five million people without any insurance. A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy--a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper--has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers. |
I'll say it again. His ability to synthesize information is just amazing. What I wouldn't give to have even half his skill. Here's another excerpt:
| "Moral hazard" is the term economists use to describe the fact that insurance can change the behavior of the person being insured. If your office gives you and your co-workers all the free Pepsi you want--if your employer, in effect, offers universal Pepsi insurance--you'll drink more Pepsi than you would have otherwise. If you have a no-deductible fire-insurance policy, you may be a little less diligent in clearing the brush away from your house. The savings-and-loan crisis of the nineteen-eighties was created, in large part, by the fact that the federal government insured savings deposits of up to a hundred thousand dollars, and so the newly deregulated S. & L.s made far riskier investments than they would have otherwise. Insurance can have the paradoxical effect of producing risky and wasteful behavior. Economists spend a great deal of time thinking about such moral hazard for good reason. Insurance is an attempt to make human life safer and more secure. But, if those efforts can backfire and produce riskier behavior, providing insurance becomes a much more complicated and problematic endeavor[...]
he moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like Nyman this assumption is plainly absurd. We go to the doctor grudgingly, only because we're sick. "Moral hazard is overblown," the Princeton economist Uwe Reinhardt says. "You always hear that the demand for health care is unlimited. This is just not true. People who are very well insured, who are very rich, do you see them check into the hospital because it's free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?" For that matter, when you have to pay for your own health care, does your consumption really become more efficient? In the late nineteen-seventies, the rand Corporation did an extensive study on the question, randomly assigning families to health plans with co-payment levels at zero per cent, twenty-five per cent, fifty per cent, or ninety-five per cent, up to six thousand dollars. As you might expect, the more that people were asked to chip in for their health care the less care they used. The problem was that they cut back equally on both frivolous care and useful care. Poor people in the high-deductible group with hypertension, for instance, didn't do nearly as good a job of controlling their blood pressure as those in other groups, resulting in a ten-per-cent increase in the likelihood of death. As a recent Commonwealth Fund study concluded, cost sharing is "a blunt instrument." Of course it is: how should the average consumer be expected to know beforehand what care is frivolous and what care is useful? I just went to the dermatologist to get moles checked for skin cancer. If I had had to pay a hundred per cent, or even fifty per cent, of the cost of the visit, I might not have gone. Would that have been a wise decision? I have no idea. But if one of those moles really is cancerous, that simple, inexpensive visit could save the health-care system tens of thousands of dollars (not to mention saving me a great deal of heartbreak). The focus on moral hazard suggests that the changes we make in our behavior when we have insurance are nearly always wasteful. Yet, when it comes to health care, many of the things we do only because we have insurance--like getting our moles checked, or getting our teeth cleaned regularly, or getting a mammogram or engaging in other routine preventive care--are anything but wasteful and inefficient. In fact, they are behaviors that could end up saving the health-care system a good deal of money. |
Be sure to click through and read his takedown of Bush's Health Savings Account initiative. And his conclusion? Imagine if politicians spoke like this:
| The issue about what to do with the health-care system is sometimes presented as a technical argument about the merits of one kind of coverage over another or as an ideological argument about socialized versus private medicine. It is, instead, about a few very simple questions. Do you think that this kind of redistribution of risk is a good idea? Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem. |
Maybe I'm naive, but one day I believe it will happen. One day we will once again have a leader who speaks to the nation as if they were adults. Teddy Roosevelt once did it. So too did Franklin. (In fact, FDR's most famous rhetorical moments, the Fireside Chats, are based entirely around that idea. Here's just one excellent example) Hell, Reagan occasionally did it, and in 1992, most of Ross Perot's entire campaign was based on long, detailed, yet easy to understand explanations of trade and budgetary policies. It can be done. One day it will be done. And when that happens, everything will change - if only for a moment... Will health care be that moment? Maybe. Maybe...
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