October 2, 2005
New York Times
In the aftermath of Hurricane Katrina, we have an opportunity to construct something far more important than higher levees - a national health care system that looks less like a tightrope and more like a safety net.
A dozen years after Bill Clinton's health reform efforts were destroyed by the insurance industry's duplicity, it's worth trying again. The health care system is steadily becoming more gummed up in ways that are impossible to hide.
One of the bumper stickers attacking the Clinton plan read: "If You Like the Post Office, You'll Love National Health Insurance." That wouldn't work today: the Postal Service runs a system that is manifestly more rational and efficient than our health care system. For starters, imagine a postal system that refused to deliver letters to or from 45 million Americans - except on rare occasions, by ambulance.
"This is one of those fleeting opportunities where a catastrophe creates an opportunity to rebuild something better than before," says Dr. Irwin Redlener, president of the Children's Health Fund and associate dean of the Mailman School of Public Health at Columbia University.
In a sign of the growing disenchantment with our health system, 13,000 doctors have joined Physicians for a National Health Program, which lobbies for a single-payer government-financed health program.
There are four main problems with the existing system. First, it leaves out 45 million uninsured Americans, and their number is rising. Second, it is by far the most expensive in the world, costing 15 percent of our national income, yet our outcomes are awful - U.S. life expectancy is worse than Costa Rica's. Third, our business competitiveness is undermined when, for example, medical expenses add $1,500 to the sticker of each General Motors car. Fourth, our system is catastrophically inefficient: according to a study in The New England Journal of Medicine, health administrative costs are $1,059 per capita in the U.S., and just $307 in Canada.
A single-payer system would be most efficient but probably is not politically feasible at the moment. The smart new book "The Health Care Mess" suggests a variety of more gradual approaches that would face less opposition.
Whatever the mechanism, all children should be covered. It's a disgrace that we use public funds to save the lives of nonagenarians but not those of 9-year-olds. And kids are a bargain: per capita medical spending is $1,525 for children less than 5, and $9,000 per person aged 65 to 74.
A second principle is that we should put less emphasis on curative medicine and more on public health and prevention - everything from preparing for avian flu to encouraging exercise. Sure, we can buy more "left ventricular assist devices," which cost $210,000 per patient installed, or buy Erbitux for colon cancer, at $17,000 per month of treatment. But as a wise new book, "Prescription for a Healthy Nation," argues, you get more bang for the buck when you promote healthier lifestyles - fighting obesity, cigarette smoking and the like.
Raising cigarette taxes saved far more American lives, for example, than an army of neurologists ever could. In the same spirit, I'd like to see a French-fry tax. And imagine the health gains if we banned potato chips and soda from schools.
Reforming the health system won't be easy. In the real world, poor kids don't see doctors not only because they're uninsured, but also because Mom doesn't have a car, can't easily get time off from work, or doesn't speak English. Those are hard nuts to crack - but one reason to think that we can do better is that much of the world does better.
I've been thinking of health care partly because of something that happened when I was on vacation in August. My kids and I were stacking firewood for my parents on the Yamhill, Ore., farm where I grew up, when suddenly the seven-foot stack collapsed - on top of my youngest. She was knocked down and pinned, her face bleeding, under a pile of logs.
I had insurance, and a car to get to the emergency room - and in the end the logs (stained with blood) turned out to be in worse shape than my daughter. She's just fine. But that instant was heart-stopping in its terror - and the system routinely does fail such children in need. Isn't it worth fighting one more time for reforms, so that we Americans can get health care every bit as good as Canada's?