To the Editor:
Eric Cohen and Yuval Levin do a fine job of laying out the complexities of our health-care system and the dilemmas that make reform a difficult task [“Health Care in Three Acts,” February]. But their summary dismissal of the universal health-care systems of other democracies is less than helpful, and I would make several corrective points.
Contrary to what they suggest, most universal systems make extensive use of market practices and are not run exclusively by government. In America, we tend to set the market and government in opposition to one another, but elsewhere government uses the market to help its policies work better.
Messrs. Cohen and Levin fail to note that there are two types of universal health-care systems: those that depend upon direct citizen taxation (such as in Canada, Britain, Australia, and Italy) and social-health-insurance systems (such as in France, Germany, Holland, and Switzerland) that are financed through mandatory contributions by employers and employees. The former are run by government while the latter make use of private insurers, though they are heavily regulated. Only the former can be called “single-payer.” Canada and the UK have by far the weakest programs—which is why they are conveniently picked upon for horror stories. But few waiting lists for medical procedures are to be found in countries with social health insurance. All provide patients with a wide range of choice in many aspects of their care.
Thus, it is a gross exaggeration for Messrs. Cohen and Levin to say that the U.S. has managed to beat back “the pressure for government-run health care of the kind for which every other developed country is paying a heavy price.” The fact is that in countries with social health insurance, the health-care inflation rate is approximately 3 to 4 percent annually, half that of our own; the overall cost of care is radically lower; life expectancies are on average two to three years greater than in the U.S.; the populations are more satisfied with their care; and there is far less economic insecurity in the face of illness. The World Health Organization has ranked the U.S. 17th on overall health-system performance, behind most of the countries with social health insurance.
An attractive feature of European approaches to health care touches on one of Messrs. Cohen and Levin’s last points. Europeans seem to understand better that “health itself always remains out of our ultimate control.” We are obsessed with health in a way Europeans are not. They understand that people get old and die, which (to judge from their rhetoric) neither the Right nor the Left in the U.S. seems to grasp. Moreover, Europeans would never think of referring to their systems as “socialized medicine,” if only because most can be traced back to the practices of 19th-century religious organizations, not to socialism. It is time to drop that tired bit of ideological rhetoric—or to begin referring to the Department of Defense’s services as “socialized protection.”
Daniel Callahan
Hastings Center
Garrison, New York
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To the Editor:
Eric Cohen and Yuval Levin raise several interesting points about the future of health care in America, but in doing so they misrepresent the workings of Australia’s health-care system. They are right that the federal government offers a 30-percent tax rebate for private care, but this covers only hospital stays. Everyone, even those with private insurance, is entitled to free treatment in public hospitals. Doctor visits, prescriptions, pathology, imaging, and so on remain the responsibility of the federal government. The balance between the public and private sectors is a subject of debate, but the overall system of guaranteed universal coverage is strongly backed by the Australian public.
Donald Potter
Hobart, Australia
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To the Editor:
As evidence of the superiority of health care in America, Eric Cohen and Yuval Levin adduce the fact that “in Germany and France, roughly half of the men diagnosed with prostate cancer will die from the disease, while in the United States only one in five will.”
This is a clear misuse of statistics, the implication being that a man is two-and-a-half times more likely to die of prostate cancer in Germany or France than in America. In fact, the mortality rate for prostate cancer is roughly the same in all three countries: 28.5 deaths per 100,000 men in the U.S., 28.58 in Germany, and 29.83 in France.
The apparent difference in cure rates is simply due to the fact that American doctors treat much younger and healthier patients. Here, the prostate specific antigen (PSA) screening test is routinely used to seek out early prostate cancer in men starting at age 50, while European health services, unconvinced that the test offers any life-saving benefit, generally do not use it.
PSA testing is quite effective at diagnosing small, early prostate cancers, most of which will never grow quickly enough to cause death, or even serious symptoms. It is only on paper that the American approach appears to save lives, but our method costs much more money, and results in far more surgeries, radiation treatments, and the serious side effects that go along with them. It is impossible to conduct any serious discussion of this subject without weighing the issues of costly overdiagnosis and overtreatment of prostate cancer and other conditions.
Peter Blau
Weston, Connecticut
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To the Editor:
Eric Cohen and Yuval Levin omit the problems that physicians have to contend with in a health-care system dominated by insurance and drug companies. As a practicing physician for over 50 years, I can report that the situation has never been worse. My ability to obtain drugs for sick patients, tests to monitor treatment outcomes, necessary hospital admissions, and the like is often determined by an impersonal employee of a drug plan or an insurance company. Bringing insurance companies into the health-care system has raised the administrative costs of health care from 7 to over 23 percent.
The authors fail to mention that the Veterans Health Administration offers the best and safest care in the country. Its drug formulary is determined by merit and not influenced by drug companies. And its administrative costs are kept to a minimum. Most doctors, as well as the American College of Physicians and the American College of Surgeons, favor a national single-payer system modeled on it.
Bernard Kabakow, M.D.
New York City
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To the Editor:
Eric Cohen and Yuval Levin offer a reasonable, balanced analysis of health-care policy. But they understate the economic trade-offs in any government-directed system and even in our current employment-based system.
The authors do not consider carefully enough the crucial issue of quality in health care. They allude to the fact that aggregate health-care outcomes in the U.S. are not better than in other advanced countries, even though we devote a higher percentage of our GDP to health-care spending. The Left takes this as evidence of the miraculous efficiency of the socialist element in other countries’ health care. But our own government programs show no signs of such supposed efficiency—our extravagant rate of expenditure shows up just as much in Medicare and Medicaid as it does among the non-elderly, non-poor segment of the population.
Quality in health care means cost-effectiveness. When one fails to receive a treatment where the average benefit exceeds the cost, that is undertreatment. When the cost of treatment exceeds its average benefit, that is overtreatment. Both types of mistakes have been found, but overtreatment is far more pervasive. And the most well-documented findings of overtreatment are in Medicare, where researchers have found vast differences in service levels across regions, with no effect on patient outcomes.
Employer-provided health coverage, insofar as it also discourages prudence and cost-consciousness, likewise contributes to the general pattern of overtreatment. Moreover, if workers knew how much their take-home pay was reduced so that their employers could “give” them health insurance, the system would not be as popular as it now appears to be. To put it another way, if health-insurance premiums paid by employers were reported and taxed as compensation, my guess is that many workers would turn down the “gift” and take the cash instead. They could then buy less expensive health insurance on their own or forgo coverage altogether.
The authors give too much praise to the Massachusetts plan for “universal private insurance coverage” as a purportedly better alternative to universal government coverage. The only hope for the Massachusetts plan, which is unraveling as I write, was that it would evade the state’s onerous regulatory mandates on insurance providers. Without such an exemption, supposedly “affordable” health insurance is going to cost $380 a month in premiums—almost double what was promised at the time the plan was enacted.
The challenge in health care is not for politicians to come up with better interventions. The challenge is for politicians to get out of the way and let consumers make choices that are unconstrained by inflationary mandates or subsidies. Messrs. Cohen and Levin object that consumers do not want to haggle with health-care providers at the point of service. But how much do they really want to pay to avoid such haggling? In any case, if Messrs. Cohen and Levin are right, then even in the absence of government subsidies, consumers would buy pre-paid health plans from third parties. Let that be an empirical question.
Arnold Kling
Cato Institute
Washington, D.C.
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To the Editor:
I wholeheartedly endorse Eric Cohen and Yuval Levin’s idea for universal private health insurance, but with the caveat that primary care should be at its center. Primary-care physicians like pediatricians, internists, and general practitioners fulfill the majority of patients’ health-care needs efficiently and cost-effectively. Insurance companies understand this, and require that any referrals to a specialist go through the family doctor’s office.
Unfortunately, there are not enough primary-care physicians today to meet the needs of those already insured, let alone for those who will be insured in the future by a universal private-insurance program. As a result, primary-care physicians are overworked, and because they are underpaid by insurance companies, they must increase their patient loads yet further to make a profit. Medical students are aware of this trend, and opt for more remunerative and less stressful specialties, leading to an even greater shortage of primary-care doctors.
One solution to this problem is a pre-paid model that some primary-care physicians, including myself, are already using. For a set fee per year or per month, patients may visit the doctor as often as necessary for acute care, chronic care, and annual screenings. This is affordable for patients, and remunerative enough for the doctor so that he can spend more time with them. Since they are paying out-of-pocket, they have an incentive to use all the services available and get the most value for their money. The doctor, meanwhile, is accountable only to them and not to an insurance company.
If the annual fee could be counted as, say, part of one’s health-insurance deductible, more people would opt for it, and it would be a useful complement to universal private health insurance.
David Marwil, M.D.
Lexington, Kentucky
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Eric Cohen and Yuval Levin write:
Daniel Callahan is as kind and spirited as ever, but he misses some key points. There certainly are important differences among the assorted universal health-care systems around the world. Some (like Canada’s) are terrible at delivering timely, quality care; others (like Germany’s) are better. But even those nations with reasonably well-functioning social-health-insurance systems pay a heavy price. Onerous taxes must be imposed to fund them, and they transform national governments into massive health and pension administrations that find a little money on the fringes of their budgets to enforce the rule of law, conduct foreign affairs, and provide for defense—although, thanks to the American security umbrella, they do not need to worry much about the latter. The problem will only worsen as the populations of Europe grow older and their collective health needs become more expensive.
On the question of finances, Mr. Callahan notes that health-care costs have grown more quickly in the United States, but he omits the fact that the economy as a whole generally grows more rapidly here as well. He also fails entirely to distinguish between private and public spending on health, taking the sum of both as a single measure of a nation’s health spending. This masks the economic burdens of a public system.
Peter Blau confuses mortality rates (a ratio of deaths from a particular cause to a given number of individuals) with fatality rates (a ratio of deaths from a particular cause to the incidence of that cause). He wrongly assumes the two would show the same results, and so tries to answer our fatality figure by comparing mortality figures in different countries. But mortality and fatality rates are only equivalent for diseases in which treatment makes little difference, so that diagnosis (which figures only into fatality statistics) becomes irrelevant. Prostate cancer is not one of them. American doctors clearly catch more cases of the disease at an earlier stage than do European doctors. The precise economic benefit of early detection is difficult to estimate, but the benefit to the quality of life of those affected is significant. In any case, we agree with Mr. Blau that any discussion of this subject must take heed of the added cost of advanced diagnostic techniques, and we were careful in our article to note that.
Bernard Kabakow makes an important point: the administrative burdens of any health-care system are an enormous burden on doctors. But the burden would only worsen under a government-financed system, as any Canadian or French physician could inform him. The Veterans Health Administration (which he puts forth as a model) and the related military program called Tricare are indeed interesting case studies. Both have enjoyed generous taxpayer support, allowing them to offer high-quality care, and both have been improved in recent years by the introduction of market mechanisms. But they also enjoy unique circumstances: Tricare, for instance, treats an exceedingly healthy portion of the population; the VA, unlike the American health-care system in general, is seeing its patient base decline, as the World War II and Korea generation is replaced by a population with a far smaller portion of veterans. At any rate, one should be careful before recommending either system as a universal model. “Walter Reed for all” is probably not a winning motto these days.
Arnold Kling makes the important point that the American health system should not be seen as an example of the free-market approach to be compared with state-run systems elsewhere. Indeed, more than 40 percent of health-care spending in America is government spending, and a great deal of the inefficiency in the health-care sector is government inefficiency. We share his concern (as we noted in our article) that the Massachusetts health-care plan leaves onerous coverage mandates in place.
We do not agree, however, with Mr. Kling’s stark assertion that “quality in health care means cost-effectiveness.” The most difficult (and expensive) health-care choices are often made in moments of desperation, when a loved one is in jeopardy and no effort seems too great. And while the economic element of health care cannot be ignored, neither can the associated human, social, familial, and political questions be translated into purely economic terms. Human beings are not the one-dimensional, rational-choice machines that many economists imagine us to be.
We agree with David Marwil’s concern that the structure of American health care is driving young doctors away from primary care. It is a serious and growing problem, and the solution he proposes is intriguing.
Finally, Donald Potter reads too much into our brief mention of the Australian system. We wrote that “Australia now offers generous tax incentives to citizens who eschew the public system for private care,” and his letter only confirms as much. We did not intend to lump Australians in with Swedes and Canadians more generally; if our Australian brothers took any hint of such an association as an insult, we apologize.
