One Nation, Uninsured/Your Money or Your Life

September 19, 2005

These two books should be read together. The first is an excellent history of the failures to reform the health-care system during the past hundred years. The second is one economist’s argument for changing the system so health care will be improved and made available for all Americans.

The authors agree that the U.S. health-care system is not a system of care for all. It is a mixture of private and public services that is often shaped more by the profit motive than by the desire to care for the health of everyone. Individual health-care workers within this nonsystem can and do struggle mightily to tend to those who are suffering and ill. Some of us see this on a daily basis.

We also see the high technology and are bombarded nightly with information about new medical breakthroughs. What we do not pay attention to are the comparative data that show that even with all its high technology, the U.S. does not do very well compared to many other Western societies. In no survey do we rank higher than 15th in health outcomes, even though we spend up to twice as much on health care as some countries that provide care for all their citizens. If we produced automobiles at nearly twice the cost of cars made by our foreign competitors, and those cars did not run as well as the foreign vehicles, would anyone buy American? Such is the health-care system we are currently purchasing.

The U.S. struggles to extend its patchwork of care. Jill Quadagno details the most recent example, the extension of Medicare through a prescription drug program. Like some other programs, this one enriches the private sector and increases the cost to taxpayers. It is of some help to the elderly who struggle with prescription costs, but it fails to address the difficulties of those without any insurance coverage at all.

What’s worse, the incentives of the U.S. health-care system favor expensive interventions; there are few incentives for the low-tech work that often leads to good health outcomes. As David M. Cutler points out, how much health-care providers are reimbursed depends on the intensity of the work being done, not on its value to good health. He proposes that we reimburse providers on the basis of results, not on the basis of how flashy a practitioner’s work is. If insurance companies reimbursed on the basis of outcomes, physicians would be rewarded for doing things currently ignored by the health-care system—for example, making follow-up phone calls that change patient behavior.

Not all the health-care news is bad. Cutler argues that the nation’s health is better today than it was 50 years ago. He is concerned, however, that the current system leads to both overuse and underuse of health care. When the system is used appropriately, it leads to good outcomes. He is not worried if the proportion of the gross domestic product spent on health care goes up as long as people receive something of value for the increase. Right now considerable waste needs to be cut out of the system. He also argues that extending health insurance to all Americans is a good investment—the benefits are greater than the costs. He thinks that all of this can be done while our current employer-based insurance system is expanded. On that matter I am not yet convinced.

Both Cutler and Quadagno think that the time to act is now. Quadagno focuses on the political will and organizational expertise that are needed to bring about reform. Cutler addresses the improvements in the system that would make universal health insurance a responsible investment. Cutler would not tie health insurance to employment but would fund his system by rescinding President Bush’s tax cuts to the wealthiest taxpayers.

What to do? The temptation for many readers, especially those who have reasonable health insurance, will be to do nothing until some feature of the health-care crisis hits home in a personal way.

Churches, of course, do a lot. Much of the care that is given in hospitals and nursing homes is provided under the auspices of religious communities; church communities often rally around people who are ill. Churches are a place where conversations can begin about the importance of health care and its meaning for us as members of communities committed to caring for the least among us. These conversations, informed by the analysis of Quadagno and Cutler, could be a catalyst for building the political will required to confront the failings of our health-care system.