It's about morality

November 2, 2009

America’s fundamental problem with health care isn’t economic. It’s moral. So believes T. R. Reid, a longtime Washington Post correspondent who recently completed a yearlong study of health-care systems in wealthy nations around the globe. “If we want to fix American health care,” he writes, “we first have to answer a basic question: Should we guarantee medical treatment to everyone who needs it?”

Reid’s book should be required reading for every senator, member of Congress, religious leader and talk-show host in America. By describing how health care works in other technologically advanced societies, he allays ideology-based fears (socialism! government takeover! higher taxes!) and offers a variety of options that we could choose among if we ever get serious about reforming our disaster-bound system.

In Reid’s view, the moral question must come first—before we discuss, say, the public insurance option, rising costs, care limitations (“rationing”) or funding. Such economic considerations are important, of course, but they do not touch the heart of the issue: “Should society guarantee health care, the way we guarantee the right to think and pray as you like, to get an education, to vote in free elections? Or is medicine a commodity to be bought and sold, a product like a car, a computer, or a camera?”

So far, Americans have been treating health care like a commodity—one that has grown expensive and unwieldy, but still a commodity. We sell it for profit, and we buy it if we have enough money. We don’t want to be forced to buy it for people who can’t afford it, any more than we’d buy them a refrigerator or a flat-panel TV. Reform health care? We see dollar signs everywhere.

By contrast, if Americans believed that adequate health care is a basic human right irrespective of ability to pay, we could devise a system that would provide it without lowering quality and without raising costs. Reid is sure of this, because every other wealthy democracy in the world has already done so.

Reid sets off on a double quest: to study health-care systems in other developed nations and to get medical advice on how to treat his injured and increasingly painful shoulder. As he makes appointments, sits in waiting rooms and discusses surgery and physical therapy and pain relievers in France, Germany, Japan, the U.K. and Canada, we not only painlessly learn how it feels to be a patient in another country but also come away with a bit of history about each country’s medical system, information on how its insurance works, and data on patient outcomes such as healthy life expectancy and avoidable mortality.

Along the way we learn startling statistics: America’s for-profit insurance companies, for example, spend 20 percent of their funds on administrative costs, whereas Medicare’s administrative costs are about 3 percent. French hospitals have 67 percent fewer administrative personnel than U.S. hospitals, but more doctors and nurses. Some 20,000 Americans “die in the prime of life each year from medical problems that could be treated, because they can’t afford to see a doctor.” (Reid’s estimate is conservative: the American Journal of Public Health recently suggested that the number is closer to 45,000.)

Reid’s survey busts a lot of popular myths. For example, universal health care is not necessarily socialized medicine: “Most wealthy countries rely on private-sector mechanisms to provide and/or pay for health care. Indeed, some foreign health-care systems are more privatized than ours.” Waiting lists are long in Canada and the U.K., but they are similar to ours in most European countries and extremely short in Japan. Rationing—that is, denying available health care for financial reasons—is less likely to happen in Europe than in America. Every country Reid studied allows free choice of primary-care physicians, with no “in-network” restrictions. Germany and Switzerland offer a wide choice of insurance companies as well. The rest of the developed world lives longer and healthier than we do, while paying considerably less for health care.

Reid’s picture of health care beyond our shores is undeniably rosy, but he does not ignore serious problems that other countries are facing. “All national health systems, even those that do their job well, are fighting a desperate battle these days against rising costs,” he writes. German doctors march in the streets to protest low fees. Half of Japan’s hospitals are in financial crisis, and many of Taiwan’s clinics and hospitals are defaulting on bank loans. Patients in the U.K. and Canada wait far too long for nonurgent surgery.

Nor is Reid blind to American achieve ments: the U.S. has “the best-educated doctors, nurses, and medical technicians of any nation,” “the best-equipped hospitals” and world-class medical research, miracle drugs and medical technology. Despite these resources, however, we lag behind the rest of the developed world in coverage, quality and cost. Which brings us back to the moral question:

Those Americans who die or go broke because they happened to get sick represent a fundamental moral decision our country has made. . . . All the other developed countries on earth have made a different moral decision. All the other countries like us—that is, wealthy, technologically advanced, industrialized democracies—guarantee medical care to anyone who gets sick. Countries that are just as committed as we are to equal opportunity, individual liberty, and the free market have concluded that everybody has a right to health care—and they provide it.

Bill Clinton, the last president to propose sweeping changes in health-care policy, may have failed because he did not understand—or at least did not adequately communicate—the moral basis of reform. Reid writes:

President Clinton emphasized economics. Health care reform, he said, was a key element of “our efforts to strengthen the economy, . . . essential to reducing the deficit and expanding investment.” . . . But the economics of change in a $2 trillion business were hardly attractive to those whose interests were tied to the status quo. . . . By early 1994, when the Clintons abandoned their plan, the central ethical argument for universal health care coverage—the notion that a wealthy country ought to provide medical treatment for all who need it—was nowhere to be heard.

Moral appeals motivate; wonkery wears us out. Does President Obama understand this basic truth of human nature? His September 9 speech to Congress, a month after Reid’s book came out, was long on economic and policy detail. The president closed, however, by calling upon those aspects of the “American character” that should move us to make health care available to all: “large-heartedness, . . . concern and regard for the plight of others, . . . our ability to stand in other people’s shoes. A recognition that we are all in this together; that when fortune turns against one of us, others are there to lend a helping hand.”

By the end of his journey, Reid’s shoulder had improved to the point that surgery was not necessary. American health care is a different story. Only major surgery will save it, but the outcome is hopeful if we are as large-hearted as our president suggests. “If Americans have the will to fix our costly, unfair health system,” Reid says, “the rest of the world can show us the way.”