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Reforming the Health Care System--Stuntz

It’s often claimed that other Western nations achieve as good or better outcomes from their nationalized health care systems as Americans achieve with our strange mix of private and government-funded health insurance—and at far less cost. Assuming that claim is true, it might be true for a reason policymakers haven’t considered. Right now, a hugely disproportionate share of the world’s medical innovation happens at the high end of America’s health care market. People like me benefit hugely from that innovation: I’m a well-insured cancer patient living near Boston, which may have the world’s highest per capita concentration of medical talent outside Rochester, Minnesota. 

But we’re not the only ones who benefit. The most successful of those medical innovations soon filter down to the rest of America’s unsystematic health care system, and then to other parts of the rich world. Those nationalized health care systems in Canada and Western Europe achieve such good outcomes partly by relying on American medical research, much of which is funded by that high-end medical market.
Why does any of this matter? It matters because we are about to take a large step toward nationalizing our own health care system. The funding has to come from somewhere, and the most natural “somewhere” is the money that now flows from companies that insure patients like me to institutions like Massachusetts General Hospital, the Mayo Clinic, or Sloan-Kettering. One must tap the money at the top of the market in order to have enough to “spread the wealth around.”
But that ignores the character of the medical market we have now. The best-off patients don’t get better care than everyone else; they get the best care sooner than everyone else. Take away the high end of America’s medical market, and a large fraction of the life-saving innovation that market produces may disappear. That will hurt all of us—in the United States and abroad.
Let me be clear: I don’t believe I have any moral entitlement to the extremely high-quality (and extremely expensive) health care I’ve gotten. I’d happily sign on to a health care system that distributed its benefits more equitably, even if I lose out in such a system. I’m less willing to go along with a system that doesn’t protect this most innovative sector of America’s economy. I hope some of the key players in the Obama Administration share that concern. I fear they don’t.


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Comments ( 2 )

The claims to which you refer at the beginning of your post are false; because the good "outcomes" in question are usually population level health statistics upon which the health system exerts relatively little effect. Diet, lifestyle, levels of violence and other cultural factors have much more to do with these outcomes than do the health systems in question. Europe looks better than we do because its people often live healthier than we do. See, for instance, McGinnis et al, "The case for more active policy attention to health promotion" Health Affairs 21(2002)2: 78-93.

if you look at health statistics for which the health system is actually important, such as survival in the 8th decade or disease-specific cancer mortality, the US is the best in the world.

I think we all need to think long and hard before we adopt nationalized health care. Part of that think should entail some common sense. As someone who has worked in health care in both the private and public sector, it's easy for me assert that private health care is far superior to public care. But let's also challenge these often quoted points:

1. The idea that folks with health insurance forego health care.

I've never witnessed a patient escorted out of a hospital because they don't health insurance. Care is not denied, but the cost is enormous.

2. Those without health insurance are the poor.

The poor have Medicaid. Those without health insurance are the middle class. Money might be tight for them, but many seem to have plenty to spend on alternative health care.

3. Healthcare is better in Canada or Europe.

If that were the case, then we'd see large numbers of Americans traveling overseas for care and few foreigners coming here. But that's just not the case: Lots of people come to the US for care and very few entertain the idea of going to Montreal when diagnosed with a serious illness.

4. Public healthcare is better at preventive care.

Maybe. But there's a real debate about whether preventive care matters. For cancer screening it does seem so, but the idea of going to your doctor every year for a physical doesn't bear much empirical fruit for better outcomes.

5. The VA is a model for healthcare.

The VA rations care. That's the only way it can afford to provide care based on its model. But rationed care is supposedly what's bad about our current system. How does this fix that?

6. US healthcare differs in speed - those without good insurance wait.

Maybe. But everyone in places that have socialized medicine wait much longer.

One of the real issues with healthcare right now in the US has to do with cost. What does a lab test cost? we really don't know b/c the true cost has been distorted for so long. Medicaid pays one amount, the private insurers another, and private payers the most. But so much of modern health care delivery in most hospitals is robbing Peter to pay Paul. Surgery services fund pediatrics; dermatology supports psychiatry. In that morass, the true cost becomes lost. So much so that we now have a healthcare system where dermatologists make $400k and primary care doctors make $120k. But which area is really more valuable to the public?