WASHINGTON - My friend Norman Macrae identified the centralproblem of health care in The Economist magazine many years ago. Theproblem, he argued, was simple and the fix impossible.
Macrae identified the obvious, which is seldom mentioned: at thetime of delivery, neither the health provider nor the patient isinterested in the cost. Ergo, health-care costs are the mostdifficult to contain.
People who do not have insurance, or who do not live in a countrywhere the government pays, do without the health care they need. Inthat respect, the market works. But if you are lying on the gurneyand you have insurance, when the nice radiologist asks you if youwant more X-rays before the operation, you do not ask what they costnor do you suggest that the surgeon proceed without additional X-rays.
The previous statement is not hypothetical. I fell off of my horseand broke my leg badly and before I was wheeled into the operatingroom, I was asked if I wanted the additional X-rays. Damn right, Idid.
Way back, when most of the advanced countries introducedgovernment-financed, single-payer health care systems, medicine wassimpler and ran more to comfort than to cure. Today we can curealmost anything and prolong life to an astounding extent - at aprice. The only country to go to nationalized health insurance inthis new regime of high-science medicine is Canada.
Most of the others, including nearly all of western Europe andJapan, introduced national health care after World War II. The commonpolitical reality is that people who have nationalized health carelove it and would not vote for an alternative private system. InBritain, for example, where the National Health Service is plaguedwith problems, no politician dares breathe the thought that it beabandoned. Think about Americans and Social Security and you will getthe picture about how the British feel about their health-caresystem. It is the third rail of British politics.
Surprisingly, none of the countries with nationalized systemsspend as much money on health care as a percentage of gross domesticproduct as does the United States, with its private insurance that isalleged to leave out 41 million people.
We spend a whopping 14 percent of our GDP on health care comparedwith between 6 percent and 11 percent for those with single-payersystems.
As my friend and colleague Martin Walker of United PressInternational points out, it comes down to rationing and where andhow you do the rationing. In Europe and elsewhere, elective surgeryand the very old bear the brunt of the rationing. You can wait twoyears in Britain for elective surgery. By contrast, we ration healthcare to young uninsured people. It is the ghetto child, the minimum-wage earner and the seasonally employed who do without in our system.
Yet American medicine is the best in the world and the time whenwe might have tried a European or Canadian system is long past.Therefore, Democratic presidential contender Dick Gephardt deservescredit for putting health care back on the national agenda and comingup with a thoughtful plan for compulsory insurance underwritten withtax credits. Not since the debacle of the Clinton health-care schemehas any politician at the national level had the courage to raise thehealth-care issue.
Gephardt asserts that his plan would be good for the economy. Youmight say, 'He would, wouldn't he?' But most small businesses -revered in the abstract by politicians - would welcome some varianceon the Gephardt plan. Yes, good, entrepreneurial, right-of-centersmall business owners.
As one myself, I would much rather be relieved of some of theburden of providing health insurance for my small staff than receiveadditional tax cuts. In this economy, many of us are not makingenough money to pay taxes, but we have to pay health insurance foremployees in good years and bad years.
Probably not very many small business owners could bringthemselves to vote for Gephardt for president because of many of hisprotectionist positions. But we should give him full recognition forraising the issue of national health insurance.
It is the crisis that does not quit.
